Clinical Guidelines Research Articles

Improving hospital care for people who use drugs: deliberative process development of a clinical guideline for opioid withdrawal management

Abstract Background Management of opioid withdrawal in hospital settings is crucial to improve treatment completion and health outcomes among patients who use opioids, such as heroin. Evidence-based clinical guidelines can support responsive provision of opioid substitution therapy (OST). In England there is no standardised application of guidance for substance dependence management across National Health Service (NHS) Hospitals. A recent review of NHS hospital policies identified varying approaches to managing opioid withdrawal and procedural barriers to timely medication. Objective To develop a clinical guideline for opioid withdrawal management in acute NHS hospital trusts to be tested and evaluated as part of the iHOST (Improving Hospital Opioid Substitution Therapy) research intervention. Methods We undertook a deliberative guideline development process. The University London College Hospital (UCLH) substance dependence guideline was used as a template, with key points of revision informed by evidence review, consultations with hospital staff and people with opioid dependence. A multidisciplinary working group deliberated evidence statements to develop recommendations. These were reviewed by an oversight committee comprising representatives from key stakeholder organisations. The team authored the guideline with iterative review by the oversight committee, key stakeholders and UCLH clinical governance committees. Results Deliberation focused on three key domains: (1) identifying opioid dependence and promptly continuing existing OST prescriptions; (2) initiating or re-titrating OST; (3) ensuring safety and continuity of care at discharge. Changes to the UCLH guideline included removal of mandatory urine drug testing prior to OST; increasing initial methadone titration dose; and provision for a higher day-one titration dose when specific safety criteria are met. A new titration schedule for sublingual buprenorphine was incorporated. Discharge planning to ensure continuity of community care and reduce risk of opioid overdose was emphasised, with allowance for bridging prescriptions of OST and naloxone provision on hospital discharge. Conclusion The iHOST clinical guideline aims to remove procedural barriers to opioid withdrawal management for hospital inpatients. It is intended to be implemented by other NHS hospitals, which could improve access to OST and reduce discrepancies in treatment access and completion. Study registration ISRCTN47320412 https://doi.org/10.1186/ISRCTN47320412.

A novel way to integrate economic information into clinical practice guidelines.

Clinical guidelines are widely used to support clinical decision making, so they could also provide economic information about medical interventions to promote cost-conscious health care. We developed a new way to integrate economic information into the Finnish Current Care Guidelines. Our development team consisted of clinical guideline specialists and health economists. We first looked at integration of economic information in clinical guidelines of other countries. Our key principle was that economic information should be integrated only to mutually exclusive medical interventions where the extensive choice of one the options will yield a significant cost differences on the national level. For the comparative effectiveness information of the interventions, we primarily looked for network meta-analyses. We then combined the effectiveness information presented as number needed to treat with prices or costs for the interventions and present the result as a cost per responder, which reflects both effectiveness and price or costs. We introduce a process to integrate and present the economic information of the selected interventions in tables in the Current Care Guidelines. Our novel way to integrate economic information into the Current Care Guidelines is an effort to support cost-conscious clinical decision making to promote cost-effective health care in Finland. This process is general and could be used in clinical guidelines in other countries as well.

Precision medicine to identify, prevent, and treat pediatric obesity.

Pediatric obesity is a growing health concern that has many secondary adverse health implications. Personalized medicine is a tool that can be used to optimize diagnosis and treatments of many diseases. In this review, we will focus on three areas related to the genetics of pediatric obesity: (i) genetic causes predisposing to pediatric obesity, (ii) pharmacogenomics that may predict weight gain associated with pharmacotherapy, and (iii) pharmacogenomics of anti-obesity pharmacotherapy. This narrative review evaluates genetic cause of pediatric obesity and how genetic findings can be used to optimize pharmacotherapy to minimize weight gain and optimize obesity treatment in pediatric patients. Pediatric obesity has many genetic causes including genomic obesity syndromes and monogenic obesity disorders. Several genetic etiologies of obesity have current or emerging targeted genetic therapies. Pharmacogenomic (PGx) targets associated with pharmacotherapy-induced weight gain have been identified for antipsychotic, antiepileptic, antidepressant therapies, and steroids, yet to date no clinical guidelines exist for application use of PGx to tailor pharmacotherapy to avoid weight gain. As legislation evolves for genetic testing coverage and technology advances, this will decrease cost and expand access to genetic testing. This will result in identification of potential genetic causes of obesity and genes that predispose to pharmacotherapy-induced weight gain. Advances in precision medicine can ultimately lead to development of clinical practice guidelines on how to apply genetic findings to optimize pharmacotherapy to treat genetic targets of obesity and avoid weight gain as an adverse event associated with pharmacotherapy.

Insights From ISASS Webinar Series on Current and Emerging Techniques in Endoscopic Spine Surgery | Part 3: A Polytomous Rasch Analysis on Surgeons' Endorsement of Multiportal Access, Treatment of Lumbar Facet Cyst, Grade I Spondylolisthesis, and Interbody Fusion.

The International Society for the Advancement of Spine Surgery hosted the third in a series of webinars focused on innovative endoscopic spine surgery techniques. This session aimed to discuss and evaluate advanced treatments for lumbar spinal stenosis and related conditions utilizing multiportal endoscopic approaches; articulating instruments; unilateral biportal endoscopy; transforaminal techniques for facet cysts, herniated disc, and spinal stenosis; as well as percutaneous endoscopic lumbar interbody fusion (PELIF). To analyze the level of surgeon endorsement for the presented endoscopic spine surgery techniques before and after the webinar, utilizing polytomous Rasch analysis, and to evaluate the potential for these insights to inform clinical guideline recommendations. An online survey was administered to 868 surgeons during a sponsored webinar hosted by the International Society for the Advancement of Spine Surgery. The survey used Likert-scale ratings to evaluate 5 main topics and additional surgical experiences and was distributed before and after the webinar. Survey responses were analyzed using descriptive statistics and Polytomous Rasch analysis to evaluate shifts in acceptance and perception. Of the 793 surgeons who attended the webinar, 229 accessed the prewebinar survey, 154 began it, and 119 completed it, yielding a completion rate of 77.3%. The respondents included 52.9% orthopedic surgeons, 37.0% neurosurgeons, 1.7% fellows, 0.8% residents, and 0.8% medical students. In the postwebinar phase, engagement remained high, with 298 accessing the survey, 169 starting it, and 128 completing it, resulting in a 75.7% completion rate. The postwebinar participant demographics closely resembled the initial distribution, consisting of 53.1% orthopedic surgeons, 35.9% neurosurgeons, 6.2% residents, 3.1% fellows, and 1.6% medical students. The confidence in various endoscopic techniques saw notable changes, particularly for procedures involving transforaminal lateral canal decompression for stenosis, herniated disc, and low-grade spondylolisthesis. Unilateral biportal endoscopy facet joint decompression and PELIF saw an increase in high-level endorsements after the webinar. Polytomous Rasch analysis provided insights into procedural techniques. The study showed consensus on the effectiveness of percutaneous endoscopic decompression of low-grade spondylolisthesis, reflecting evolving surgeon preferences and consensus on best practices. Infit and outfit statistics from the Rasch analysis suggested a good fit between the survey responses and the Rasch model both before and after the webinar, indicating minimal data distortion due to bias except for transforaminal decompression for posterolateral and central herniated nucleus pulposus. Differential item functioning analysis showed no significant bias in item responses between orthopedic surgeons and neurosurgeons in the prewebinar survey but identified potential bias for 1 item postwebinar in PELIF and articulating instruments. The webinar influenced surgeon perceptions and endorsements of advanced endoscopic techniques, substantially impacting professional practice. Continued use of Rasch analysis in evaluating educational interventions offered a nuanced understanding of changes in surgical practice toward more complex and controversial issues such as central and migrated herniated nucleus pulposus, facet cyst, low-grade spondylolisthesis, and fusion while potentially guiding future clinical guidelines and training programs to align with evolving endoscopic techniques. Assessing surgeon confidence and acceptance of endoscopic spinal surgeries using polytomous Rasch analysis. Level 2 (inferential) and 3 (observational) evidence because Rasch analysis provides statistical validation of instruments rather than direct clinical outcomes.

Key Takeaways From the ISASS Webinar Series on Current and Emerging Techniques in Endoscopic Spine Surgery | Part 2: Polytomous Rasch Analysis of Learning Curve and Surgeon Endorsement of Biportal, Interlaminar, and Transforaminal Endoscopic Stenosis Decompression, Discectomy, and Laminectomy in Combination With Interspinous Process Spacers.

The International Society for the Advancement of Spine Surgery hosted the second of a series of 4 webinars on endoscopic spine surgery techniques. The second webinar focused on the application of unilateral biportal endoscopy for discectomy and laminectomy in combination with interbody fusion and interspinous process spacers. This series was intended to identify current trends with contemporary modern endoscopic spine surgery techniques. To analyze the level of surgeon endorsement for the presented endoscopic spine surgery techniques before and after the webinar utilizing polytomous Rasch analysis, as well as to evaluate the potential for these insights to inform clinical guideline recommendations. A survey was available to 667 potential respondents during the Zoom webinar, collecting data on surgeon endorsements using a Likert scale. The polytomous Rasch model was employed to analyze responses while considering the complexity of decisions against surgeon expertise, developing a logarithmic measurement scale, allowing objective statistical analysis of categorical variables, highlighting incongruent or out of order items vs congruent and in order items, and driving improvement in clinical guidelines. Of the 667 surgeons who participated in the webinar, 224 accessed, 122 started, and 61 completed the prewebinar survey, achieving a 50.0% completion rate. Respondents comprised primarily orthopedic surgeons (70.5%) and neurosurgeons (24.6%), with fellows and medical students each making up 1.6%. These surgeons estimated that mastering the learning curve of endoscopic spine surgery required an average of 18.08 cases corroborated by postwebinar responses averaging 15.78 cases. Descriptive statistics revealed an acknowledgment of a learning curve in mastering endoscopic spine surgery, with a slight increase in recognition postwebinar (81.8% up from 80.3%). The data underscored the importance of cadaver courses and high-volume surgical practice before the webinar and highlighted the value of mentorship afterward, indicating a preference shift toward more interactive learning. The confidence in various endoscopic techniques saw notable changes, particularly for procedures involving interlaminar lateral canal decompression and the combined use of transforaminal endoscopic decompression with interspinous process spacers, which saw an increase in high-level endorsements postwebinar. Polytomous Rasch analysis provided insights into training methods and procedural techniques, with mentorship and cadaver courses emerging as key elements for mastering the learning curve. The analysis also highlighted a general consensus on the effectiveness of percutaneous endoscopic interlaminar decompression for lateral canal stenosis, reflecting evolving surgeon preferences and consensus on best practices. Infit and outfit statistics from the Rasch analysis suggested a good fit between the survey responses and the Rasch model both before and after the webinar, indicating minimal data distortion due to bias. Differential item functioning analysis showed no significant bias in item responses between orthopedic surgeons and neurosurgeons in the prewebinar survey, but it identified potential bias for one item postwebinar-unilateral biportal endoscopic laminectomy for central stenosis. This webinar highlighted the importance of hands-on training methods such as cadaver courses and mentorship in mastering the complex spinal endoscopy procedures. The application of polytomous Rasch analysis provided a detailed understanding of surgeons' current preferences and perceptions, as well as the evolving consensus on best practices in endoscopic spine surgery, displaying wide acceptance of the percutaneous interlaminar endoscopic decompression for lateral canal stenosis decompression and a growing interest in integrating endoscopic techniques for more comprehensive spinal care, including wide decompression and spinal stabilization. Assessing surgeon confidence and acceptance of endoscopic spinal surgeries using polytomous Rasch analysis. Level 2 (inferential) and 3 (observational) evidence because Rasch analysis provides statistical validation of instruments rather than direct clinical outcomes.

Should all people starting urate-lowering therapy for gout receive anti-inflammatory prophylaxis?

Co-prescription of anti-inflammatory prophylaxis with colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), or corticosteroids when initiating urate-lowering therapy (ULT) for gout is recommended in clinical guidelines to prevent ULT-induced flares and optimise adherence to ULT. Colchicine prophylaxis is highly clinically and cost-effective and there has been great interest recently in its cardioprotective effects. However, one in four people initiating ULT without prophylaxis in randomised trials do not have a gout flare within six months of initiation, raising the question of whether all people initiating ULT for gout should receive prophylaxis. Uptake of prophylaxis varies and appears to be common in secondary care settings but less commonly used in primary care, where most people with gout are managed and gout may be less severe. Recent clinical guidelines have highlighted that the patient’s perspective is important and that the pros and cons of prophylaxis should be discussed with people with gout initiating ULT. Uptake of prophylaxis seems likely to be influenced by perception of an individual’s risk of ULT-induced flares, as well as concerns about adverse events, polypharmacy, drug interactions, and cost. We advocate a personalised approach between people with gout and clinicians to reach shared treatment decisions when considering co-prescription of prophylaxis when initiating ULT, empowering people with gout to make decisions about their care.

Isolation and Identification of Bacterial Pathogens from Blood Cultures in a Tertiary Care Hospital and Their Clinical Correlation

Objective: This study aimed to isolate and identify bacterial pathogens from blood cultures of patients with suspected bloodstream infections (BSIs) in a tertiary care hospital, analyze their antimicrobial susceptibility patterns, and establish clinical correlations. Methods: A cross-sectional study was conducted in the Microbiology Department of a tertiary care hospital. Blood samples from 60 patients were collected aseptically, processed using BACTEC, and cultured on blood and MacConkey agar. Bacterial isolates were identified based on colonial morphology, Gram staining, and biochemical tests. Antibiotic susceptibility testing was performed using the modified Kirby-Bauer disk diffusion method according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: The overall culture positivity rate was 26%, with higher positivity among female patients (31.57%) and neonates or infants under six months (26%). Klebsiella pneumoniae was the most frequently isolated pathogen (53.33%), followed by Staphylococcus aureus (20.00%), Escherichia coli (13.33%), and Citrobacter species (13.33%). Klebsiella pneumoniae showed high resistance to ceftazidime and piperacillin, while remaining sensitive to cefoperazone and tobramycin. Staphylococcus aureus isolates were resistant to penicillin and erythromycin but sensitive to vancomycin and cefazolin. The prevalence of multidrug resistance among isolates underscores the need for targeted empirical therapy. Conclusion: Klebsiella pneumoniae emerged as the primary pathogen in BSIs, with significant resistance to commonly prescribed antibiotics. These findings highlight the necessity for enhanced infection control measures, especially in NICUs, and the implementation of local antibiograms to guide effective antibiotic therapy and mitigate resistance trends. Further research across multiple centers is recommended to validate these findings and inform broader clinical guidelines.

Key Takeaways From ISASS Webinar Series on Endoscopic Spine Surgery Techniques | Part 4: Advancing the Curve on Surgeons' Experience With Complex Lumbar Revision Scenarios, Grades 1 to 3 Spondylolytic Spondylolisthesis, Cervical Foraminotomy, and Cervical Spondylotic Myelopathy.

The fourth webinar in a 4-part series hosted by the International Society for the Advancement of Spine Surgery explored contemporary endoscopic spine surgery techniques. This session covered complex revision strategies, endoscopic management of grades 1-3 spondylolytic spondylolisthesis, cervical foraminotomy, and decompression techniques for cervical spondylotic myelopathy (CSM). The aim was to assess surgeon endorsement of the discussed endoscopic spine surgery techniques both before and after the webinar using polytomous Rasch analysis. Additionally, the analysis sought to determine how these insights might shape clinical guideline recommendations. Before the webinar, which was attended by 868 potential participants, a survey was distributed to collect data on the level of support for various techniques using a Likert scale. The polytomous Rasch model analyzed these responses by evaluating decision complexity relative to surgeon expertise. This approach helped develop a logarithmic scale to objectively analyze categorical responses, distinguish between congruent and incongruent items, and contribute to the enhancement of clinical guidelines. Of the 868 surgeons, 263 accessed, 150 started, and 118 completed the prewebinar survey, with a completion rate of 78.7%. The participants were mainly orthopedic surgeons (59.3%) and neurosurgeons (34.7%) but also included residents (2.5%), fellows (1.7%), and interventional radiologists (1.7%). In the postwebinar phase, 298 participants accessed the survey, 169 started it, and 128 completed it, achieving a 75.7% completion rate. The demographics of postwebinar participants closely mirrored the initial group: 66.4% orthopedic surgeons, 23.4% neurosurgeons, 3.6% residents, 2.9% fellows, 0.7% medical students, and 2.9% interventional radiologists. The Rasch analysis confirmed high surgeon confidence for the posterior cervical foraminotomy and endoscopic treatment of spondylolytic spondylolisthesis grades 1 to 3 and posterior endoscopic decompression for CSM. Both pre- and postwebinar responses showed a good fit to the Rasch model for these endoscopic techniques, indicating minimal bias, supported by differential item functioning analysis. The application of the endoscopic surgery platform for procedures such as lumbar revision surgery for adjacent segment disease or failed interbody fusion cages and posterior decompression of CSM saw little shift in endorsement, as evidenced both in descriptive and the logarithmically transformed Rasch statistics. This webinar highlighted the evolving consensus on best practices in endoscopic spine surgery, displaying wide acceptance of endoscopic debridement of spondylolytic spondylolisthesis, cervical foraminotomy for herniated disc and bony stenosis, and posterior endoscopic decompression for CSM. Assessing surgeon confidence and acceptance of endoscopic spinal surgeries using polytomous Rasch analysis. Level 2 (inferential) and 3 (observational) evidence because Rasch analysis provides statistical validation of instruments rather than direct clinical outcomes.

A model for integrating palliative care into Eastern Mediterranean health systems with a primary care approach.

Palliative care in the Eastern Mediterranean Region (EMR) faces challenges despite the high number of patients in need. To provide accessible, affordable, and timely services, it is crucial to adopt a suitable care model. World health organization (WHO) recommends integrating palliative care with primary health care (PHC). Given the unique conditions of EMR countries, there is a need to design a model tailored to these contexts. This study is a multi-method research project conducted through several sub-studies, including a literature review, policy analysis, expert opinion (Delphi Method), dimension-specific analysis, model development, and its validation and refinement (Delphi Method). Drawing from the WHO model, six dimensions: policy, drug availability, education, community integration, service delivery, and research were considered to developing the model and implementation requirements. Within each dimension, evidence-based solutions tailored to the region's context were explored. A successful palliative care model requires, in the policy dimension, oversight by the Ministry of Health (MOH). Having a focal-person or working group within the MOH is crucial for policy-making, formulation, and approval of clinical guidelines, as well as addressing care challenges. It is essential to provide access to morphine and other essential medications, along with facilitating the administration and consumption of morphine at home. Conducting empowerment courses for care providers, can address various challenges. Community involvement through volunteers, charities, and non-governmental organizations (NGOs) is also important. To ensure service provision, monitoring and evaluating systems are crucial, along with striving for service continuity through an appropriate payment system. Lastly, research is necessary for needs assessment, evidence-based practice, and designing evaluation indicators. The proposed model relies on community health workers, especially nurses, as multitasking professionals available for community palliative care. In the presented model, special attention has been given to networking, collaboration, and the use of digital health technologies to support nurses. The model proposed for integrating palliative care into PHC should serve as a framework that enhances access to available and affordable services for countries in the region. While this model was developed based on the overall conditions of the region, each country can tailor it to its unique strengths and opportunities.

Moderate-Intensity Statin Plus Ezetimibe: Time to Rethink it as an Optimal Initial Lipid-Lowering Strategy.

Achievement of low-density lipoprotein cholesterol (LDL-C) targets is crucial for the prevention of cardiovascular disease (CVD) in individuals with dyslipidaemia who are at high risk. Current guidelines recommend high-intensity statins at the highest tolerated dose as initial treatment to achieve LDL-C goals. However, the real-world situation is dismal: high-intensity statins are underused and achievement of LDL-C goals is suboptimal. Various challenges exist in the implementation of the recommended initial treatment strategy, including hesitancy to use high-intensity statins, non-adherence, and side effects, and the response to high-intensity statins varies across individuals. Emerging studies have shown another line of lipid-lowering, moderate-intensity statins in combination with ezetimibe, presenting considerable efficacy/effectiveness, along with better safety and adherence compared to statin intensification alone. Here we review the clinical evidence, treatment guidelines and challenges associated with high-intensity statins, and summarise the evidence on the combination therapy, moderate-intensity statin plus ezetimibe, which is the core strategy recommended by the 2023 Chinese Guideline for Lipid Management, as a possible primary treatment to achieve the LDL-C targets across several populations. The upfront use of a moderate-intensity statin plus ezetimibe may improve LDL-C control and lead to the prevention of CVD in real-world settings.

Initiating Prognostic Talk During Hospice Multidisciplinary Team Meetings: A Conversation Analytic Study.

Objective: Guidelines recommend that patients' prognoses should be discussed by the palliative care multidisciplinary team. However, there is a lack of evidence on how multidisciplinary teams carry out prognostic discussions, and especially how prognostic talk is initiated during team meetings. This study explored how prognostic talk is initiated and responded to during meetings of a hospice multidisciplinary team. Methods: Video-recordings of 24 inpatient multidisciplinary team meetings in a UK hospice were collected from May to December 2021. A total of 65 multidisciplinary team members participated in the meetings. Recordings were transcribed and analysed using Conversation Analysis. Results: Prognostic talk was initiated during multidisciplinary team members' patient case presentations. Case presentations followed a certain template, and prognoses could be initiated as responses to template items such as the patient's Phase of Illness and Karnofsky's Performance Status score and the patient's main diagnosis and issues. Prognoses also occurred as accounts for a lack of template item responses. Beyond the patient case presentation, prognostic talk was initiated in relation to discharge planning. Prognoses appeared with sequences of assessments that accounted for them. When a prognosis was provided, it received confirming minimal responses from other team members. Conclusions: Patients' prognoses were embedded into other care discussions during meetings of a hospice multidisciplinary team. These findings can be used to inform the development of clinical guidelines and interventions aiming at improving multidisciplinary team discussions around prognosis in the future.

The BrEasT cancer afTER-CARE (BETTER-CARE) programme to improve breast cancer follow-up: design and feasibility study results of a cluster-randomised complex intervention trial.

The risk of breast cancer patients for long-term side effects of therapy such as neurotoxicity and cardiotoxicity as well as late effects regarding comorbidities varies from individual to individual. Personalised follow-up care concepts that are tailored to individual needs and the risk of recurrences, side effects and late effects are lacking in routine care in Germany. We describe the methodology of BETTER-CARE, a parallel-arm cluster-randomised controlled trial conducted at 15 intervention and 15 control centres, aiming to recruit 1140 patients, and the results of the pilot phase. The needs- and risk-adapted complex intervention, based on existing development frameworks, includes a multidisciplinary network and digital platforms for symptom and need documentation and just-in-time adaptive interventions. The control group comprises usual care according to clinical guidelines. The primary outcome is health-related quality of life (EORTC QLQ-C30 global health), and secondary outcomes include treatment adherence. The 2-month pilot phase comprising 16 patients in one intervention and one control pilot centre demonstrated the feasibility of the BETTER-CARE approach. BETTER-CARE is a feasible intervention and study concept, investigating individualised needs- and risk-adapted breast cancer follow-up care in Germany. If successful, the approach could be implemented in German routine care. German Clinical Trial Register DRKS00028840. Registered on April 2022.

Management of Atrial Fibrillation.

This JAMA Clinical Guidelines Synopsis summarizes the 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation.

Tramadol use for chronic pain management: A thorough analysis of safety, effectiveness, and clinical recommendations

Chronic pain, especially arthritis-related pain, represents a significant medical challenge worldwide. Tramadol, a centrally acting analgesic, has emerged as a valuable treatment option for managing chronic arthritis pain. This review article provides a comprehensive analysis of tramadol’s role in chronic pain management, emphasizing its safety, effectiveness, and clinical guidelines. Literature indicates that tramadol, whether used alone or in combination therapies, effectively treats various types of arthritis-related pain, such as musculoskeletal pain, osteoarthritis, and rheumatoid arthritis. While some clinical guidelines recommend tramadol as a first-line option for persistent knee or hip osteoarthritis, others urge caution due to concerns over potential abuse and negative effects. Tramadol’s mechanism of action involves, among other things, stimulation of opioid receptors and inhibition of serotonin and norepinephrine reuptake, contributing to its analgesic effects while attempting to minimize the side effects associated with traditional opioids. However, tramadol is not without side effects, including nausea, vomiting, constipation, respiratory depression, and withdrawal symptoms if it is suddenly discontinued. Despite these challenges, tramadol remains a valuable component in managing chronic pain, especially in patients with concurrent conditions and comorbidities. Further research is necessary to determine the optimal use of tramadol and to establish its risk-benefit profile across diverse patient populations.

Non-invasive testing in metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously referred to as non-alcoholic fatty liver disease (NAFLD), is a leading cause of chronic liver disease, affecting up to 30% of the global population. MASLD is strongly associated with metabolic risk factors such as obesity and type 2 diabetes, and can progress to advanced stages including cirrhosis and hepatocellular carcinoma. Early diagnosis and accurate staging of fibrosis are critical in managing the disease and preventing complications. While liver biopsy has long been considered the gold standard for assessing fibrosis, it is invasive and carries associated risks. In response, non-invasive tests (NITs) have emerged as essential alternatives for the diagnosis and monitoring of MASLD. Key methods include blood-based biomarkers such as the Fibrosis-4 (FIB-4) score, NAFLD Fibrosis Score (NFS), and Enhanced Liver Fibrosis (ELF) test, as well as imaging modalities like vibration-controlled transient elastography (VCTE) and magnetic resonance elastography (MRE). These tests provide safer, more accessible methods for identifying liver fibrosis and guiding clinical management. They are integral in assessing disease severity, guiding treatment decisions, and monitoring disease progression, particularly in light of emerging therapies. NITs have become increasingly recommended by clinical guidelines as they reduce the need for invasive procedures like liver biopsy, improving patient care and outcomes. In conclusion, non-invasive testing plays a crucial role in the effective management of MASLD, offering reliable alternatives for diagnosis and monitoring while minimizing risks associated with traditional invasive methods.

FISIOTERAPIA NO ZUMBIDO SOMATOSENSSORIAL: REVISÃO SISTEMÁTICA

Somatosensory tinnitus is a type of tinnitus that can be influenced by musculoskeletal and somatic factors, such as cervical or temporomandibular disorders. Physiotherapy has emerged as a noninvasive treatment option with the aim of addressing these musculoskeletal abnormalities to reduce tinnitus intensity and improve patients' quality of life. This review aims to evaluate the effectiveness of physiotherapeutic approaches in the management of somatosensory tinnitus, exploring different treatment modalities and the results obtained in clinical studies. The article was analyzed through clinical trials and observational studies were conducted, focusing on the impact of physiotherapy on somatosensory tinnitus, using outcome measures such as the Visual Analog Scale (VAS) for tinnitus intensity and the Tinnitus Handicap Inventory (THI) for quality of life. Most studies reported significant improvements in tinnitus severity and functional well-being of patients after physiotherapy interventions. Techniques such as manual therapy and myofascial release have been particularly effective in reducing symptoms in patients with cervical or temporomandibular disorders. However, a major limitation identified was the lack of standardized treatment protocols, which makes it difficult to generalize the results. Physiotherapy appears to be a promising therapeutic option for somatosensory tinnitus, particularly for patients with associated cervical and temporomandibular disorders. Future research should aim to standardize treatment protocols and include larger randomized controlled trials to further validate these findings and establish evidence-based clinical guidelines.

Prevention of infectious complications after radical cystectomy: a systematic review and meta-analysis

The aim of this study was to conduct a systematic review and meta-analysis of the literature to evaluate the impact of different antibiotic prophylaxis (АР) strategies on the incidence of infectious complications within 30 days after radical cystectomy (RC).Material and Methods. The meta-analysis protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO): ID-CRD42023480525. A systematic search for studies published in the last 10 years (November 2013 – November 2023) was conducted in the PubMed and Cochrane Library databases by two independent researchers. A total of 7 full-text articles were included in the final statistical analysis (data from 90,935 patients). The analysis focused on three aspects: comparison of the effectiveness of different durations of antibiotic prophylaxis (24 hours or more), the impact of the type of antibacterial agent used, and the application of Enhanced Recovery after Surgery (ERAS) protocols on the overall incidence of infectious complications, the development of soft tissue infections, and upper urinary tract infections (UTIs). Meta-analysis was performed using R 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria) and the metafor 4.2-0 package.Results. The median overall incidence of infectious complications was 31.78 % (23.8–58.8 %), surgical site infections – 16.46 % (6.25–35.41 %), and UTIs – 25.11 % (3.86–35.7 %), including cases leading to urosepsis. The meta-analysis did not reveal a statistically signifшcant effect of the duration of AP (24 hours or more) on the risk of infectious complications: for overall infectious complications, the risk was OR 1.11 (95 % CI 0.92–1.33; p=0.27), for surgical site infection OR 1.00 (95 % CI 0.87–1.15; p=0.97), and for UTIs OR 0.96 (95 % CI 0.84–1.10; p=0.59). However, the overall incidence of infectious complications was significantly higher in the standard perioperative management group, without ERAS protocols (OR=3.02 [95 % CI 2.07; 4.39], p<0.001, I 2 =93.1 %). Conclusion. The results of this study indicate that existing AP strategies may be ineffective in reducing postoperative infectious complications in patients undergoing cystectomy with urinary diversion. Extending AP beyond 24 hours, as well as the standard regimen, did not demonstrate a reduction in infection risk, highlighting the need for a revision of clinical guidelines in this area. The principles of the ERAS program may play a crucial role in reducing infectious complications, showing promising results and requiring further research and implementation in clinical practice. Key words: radical cystectomy, antibiotic prophylaxis, complications, surgical site infection, upper urinary tract infections, ERAS> ˂ 0.001, I2 =93.1 %).Conclusion. The results of this study indicate that existing AP strategies may be ineffective in reducing postoperative infectious complications in patients undergoing cystectomy with urinary diversion. Extending AP beyond 24 hours, as well as the standard regimen, did not demonstrate a reduction in infection risk, highlighting the need for a revision of clinical guidelines in this area. The principles of the ERAS program may play a crucial role in reducing infectious complications, showing promising results and requiring further research and implementation in clinical practice.

Clinical applications of fibroblast activation protein inhibitor positron emission tomography (FAPI-PET)

AbstractThe discovery of fibroblast activation protein inhibitor positron emission tomography (FAPI-PET) has paved the way for a new class of PET tracers that target the tumor microenvironment (TME) rather than the tumor itself. Although 18F-fluorodeoxyglucose (FDG) is the most common PET tracer used in clinical imaging of cancer, multiple studies have now shown that the family of FAP ligands commonly outperform FDG in detecting cancers, especially those known to have lower uptake on FDG-PET. Moreover, FAPI-PET will have applications in benign fibrotic or inflammatory conditions. Thus, even while new FAPI-PET tracers are in development and applications are yet to enter clinical guidelines, a significant body of literature has emerged on FAPI-PET, suggesting it will have important clinical roles. This article summarizes the current state of clinical FAPI-PET imaging as well as potential uses as a theranostic agent.

Development of clinical questions and outcomes on Clinical Practice Guideline of Fire Needling Therapy for Herpes Zosters

To develop the clinical questions and outcomes of Clinical Practice Guideline of Fire Needling Therapy for Herpes Zosters based on Norms of Formulation and Evaluation for the Clinical Guideline on Acupuncture and Moxibustion released by World Federation of Acupuncture and Moxibustion Societies. Combined the investigation with expert consultation and consensus method, and taken clinicians (members) of Chinese Association of Acupuncture and Moxibustion as the subjects, the clinical questions concerned were collected and the two-round consultation was conducted among expert group by letter. In the first round questionnaire, using the voting method, the relevant clinical questions in intervention measures were collected; and in the second round, with the Delphi method adopted, the importance of clinical questions and outcomes in the investigation was scored. A total of 200 structured clinical questions proposed by 153 clinicians and the clinical experience with 13 kinds of combined therapies involved and fire needling as the key measure were collected. The authority coefficient (Cr) of the Delphi questionnaire was >0.70, and the coefficient of variation for the importance scores of alternative clinical questions and outcomes was 0.06-0.26 and 0.12-0.47, respectively. The top 10 clinical questions and 12 outcomes (6 outcomes referred to the patients either in the acute stage or the post-neuralgia stage) were included, with the importance score of clinical questions>4, the importance score of outcomes>6, and the coefficient of variation ≤0.25. The clinical questions and outcomes of Clinical Practice Guideline of Fire Needling Therapy for Herpes Zosters are formulated, which provides the research basis for the recommendation development of the guideline.

How do patients and healthcare professionals experience foot examinations in diabetes care? - A randomised controlled study of digital foot examinations versus traditional foot examinations.

Digital solutions in healthcare can facilitate and improve care. However, the experiences and the usefulness of using either digital foot examinations or traditional foot examinations need to be evaluated. The aims of the study were to evaluate: 1) The differences in patient experiences, having their foot examined supported by the Clinical Decision Support System as compared with having their foot examined in traditional practice, 2) How healthcare professionals, by using the digital tool, experienced the routine compared with performing the foot examination as in traditional practice. Of a total of 141 patients, 100 patients with diabetes were single-blind digitally randomised to one of two parallel arms: having their foot examined by a healthcare professional using a digital tool (n = 47) or having their foot examined as in traditional practice (n = 53) at the Department of Prosthetics and Orthotics at Sahlgrenska University Hospital, Gothenburg, Sweden. Patients filled in a modified version of the National Patient Survey and the Orthotics and Prosthetics Users' Survey at study end. Two healthcare professionals, working at a Department of Prosthetics and Orthotics, answered surveys regarding the interaction between the patient and the certified prosthetist and orthotist. Patients, aged 66 ± 13 years, perceived a high level of satisfaction with the service at the department, regardless of the method used. No significant differences between groups were found when evaluated by 27 questions in the National Patient Survey or by the Orthotics and Prosthetics Users' Survey, with scores of 67.17 ± 12.18 vs. 66.35 ± 16.52 (p = 0.78) for the intervention and control group respectively. For the same patient that healthcare professionals foot examined, the risk class was fully obtained when the risk to develop foot ulcers was assessed by using the digital tool, whereas only 2% of the patients were classified when foot assessed in traditional practice. Regardless of the method used for the foot examination, patients perceived a high level of satisfaction with the services at the Department of Prosthetics and Orthotics. All the patients were risk classified in the intervention group. The healthcare professionals found that, by using the Clinical Decision Support System, the foot examination was structured and followed clinical guidelines. Furthermore, the documentation in the electronic health record was thorough, even though further improvements, such as integration with co-existing health record systems, were requested. Clinical Trials NCT03088566 , Registered 23 March 2017.