Development Of Clinical Pathway Research Articles

System building and improvement for the diagnosis and treatment of rare diseases in Shanghai, China.

Shanghai has always attached importance to the prevention and treatment of rare diseases and has been at the forefront in China. The Shanghai Rare Diseases Diagnosis and Treatment Center, Shanghai Children's Rare Diseases Diagnosis and Treatment Center, and Shanghai Rare Diseases Specialist Clinic were established in February 2018. Moreover, with the development of clinical pathways for rare diseases and the provision of related services such as diagnosis, treatment, screening, information and training, the service system for diagnosis and treatment of rare diseases in Shanghai has formed, which greatly improves the accessibility of medical services for patients with rare diseases in Shanghai and surrounding areas, and is of great significance in reducing the burden on patients with rare diseases. Meanwhile, it also gives an important reference for other regions of China for providing rare disease diagnosis and treatment services.

1869. Telepharmacy Support of an Antimicrobial Stewardship Program in a Small Rural Canadian Acute Care Hospital

BackgroundIn 2013 Accreditation Canada identified an Antimicrobial Stewardship Program (ASP) as a Required Organizational Practice in all acute care hospitals. A successful antimicrobial stewardship program is interdisciplinary and involves clinical pharmacists as a key member of the team. This small rural acute care hospital utilizes a telepharmacy model of care with a remote clinical pharmacist. This hospital is a 20-bed acute care hospital with no on-site clinical pharmacist and has been utilizing Telepharmacy services since 2008. To prepare for Accreditation in December 2013, the remote clinical pharmacist was requested to support and lead the antimicrobial stewardship program.MethodsThe remote clinical pharmacist performed a gap analysis to identify areas requiring improvement for a successful ASP which included the need for an Antimicrobial Stewardship committee, an IV to PO conversion program for antibiotics, development of guidelines and clinical pathways for common infections, hospital specific antibiogram, and prospective audit with intervention and feedback. The remote clinical pharmacist participated in meetings with nurses, physicians, and other key stakeholders using videoconference technology to develop a plan for the ASP. The remote clinical pharmacist started prospective data collection in September 2013. Starting January 2014, the remote clinical pharmacists started providing prospective audit with intervention and feedback.ResultsThe antimicrobial stewardship program was formally accepted by Accreditation Canada in December 2013.Figure 1.Days of Therapy (DOT) per 1,000 Patient-Days Over 4 YearsConclusionSmall rural and remote acute care hospitals without access to an on-site clinical pharmacist can successfully implement and maintain an ASP by seeking support from experienced remote clinical pharmacists.Disclosures S. Dhaliwall, Northwest Telepharmacy Solutions: Employee, Salary. K. McDonald, Northwest Telepharmacy Solutions: Employee, Salary.

52P - Molecular tumor board (MTB): Development of clinical pathways for precision medicine. Experiences of center for breast cancer at national cancer center, Korea

52P - Molecular tumor board (MTB): Development of clinical pathways for precision medicine. Experiences of center for breast cancer at national cancer center, Korea

Status quo analysis of the development of clinical pathway for bronchial pneumonia in China

This paper reviewed the content, outcome index and variations of clinical pathway of bronchopneumonia. Given the short history of such clinical pathway in China, it proves an efficient reform for curbing irrational growth of hospital expenses and reduce days of day by numerous literature. Yet further implementation and supervision are still expected. Key words: Bronchial pneumonia; Clinical pathway; Outcomes; Index

PHP194 - THE EMA CLINICAL DATA WEBSITE: A CONCEPTUAL EXPLORATORY APPROACH TO BENCHMARK CLINICAL DEVELOPMENT INDICATORS IN MARKETING AUTHORIZATIONS

The European Medicines Agency (EMA) policy on clinical data publication entered into force on 1 January 2015. Data have been regularly uploaded and are accessible to the public on the EMA Website. For the first time clinical study reports of the full clinical development have been made available. The aim of this study is to give an overview on the number and types of trials published and to analyze clinical development pathways. All available initial marketing applications on the EMA Clinical Data Website up to 1 April 2018 were analyzed. A total of 3974 documents on the website were manually reviewed by application category and analyzed iteratively. Data extraction was time-consuming. From 86 dossiers published, 55 Initial Marketing Authorizations (IMA) were available from 37 applicants for 48 indications. The 55 IMA were categorized into 17 generic, 3 biosimilar, 10 orphan and 25 other applications, by the EMA. In total 610 study reports were available, 348 phase I, 81 phase II, 124 phase III, 15 phase IV and 42 clinical studies without a designated phase. Not all studies were available, e.g. fixed-dose combination IMA did not necessarily contain all studies from individual substance development pathways. The median time from first subject-in (FSI) in the first phase I to the FSI in phase II was found to be 24 months (Interquartile range [IQR]: 9, 38) for 19 IMA. The median time from FSI in the first phase I to the FSI in phase III was found to be 55 months (IQR: 30, 62). The availability of clinical study reports and appendices, e.g. protocol, permit an insight into the strategic decision making process of clinical trial development pathways. Phase I study reports constitute a considerable percentage of the studies. Phase III studies started in the latter half of the development pathway.

Foreign Body Ingestions: Approach to Management

This article reviews the diagnosis, evaluation, pre-intervention preparation, and endoscopic management of pediatric foreign body ingestion, which is a commonly encountered problem that may present a challenge for healthcare providers and has a potential for significant morbidity and mortality. While the lack of randomized controlled trials in this area remains, recent literature has shed light on new imaging methods to localize foreign bodies and evaluate for complications, new types of foreign body ingestions, and updated management paradigms. Pediatric foreign body ingestions should be treated as emergencies. If clinically indicated, endoscopy has been shown to be safe, successful, and cost-effective with low rates of complication. Management depends on the size, location, and type of foreign body ingested. Development of clinical pathways for management of foreign body ingestion can be a useful tool for this patient population.

Evidence-based Chinese medicine：theory and practice

The introduction and popularization of evidence-based medicine has opened up a new research field of clinical efficacy evaluation of traditional Chinese medicine(TCM), produced new research ideas and methods, and promoted the progress of clinical research of TCM. After about 20 years assiduous study and earnest practice, the evidence based evaluation method and technique, which conforms to the characteristics of TCM theory and practice, has been developing continuously. Evidence-based Chinese medicine (EBCM) has gradually formed and become an important branch of evidence-based medicine. The basic concept of evidence-based Chinese medicine: EBCM is an applied discipline, following the theory and methodology of evidence-based medicine, to collect, evaluate, produce, transform the evidence of effectiveness, safety and economy of TCM, to reveal the feature and regular pattern of TCM taking effect, and to guide the development of clinical guidelines, clinical pathways and health decisions. The effects and achievements of EBCM development: secondary studies mainly based on systematic review/Meta-analysis were extensively carried out; clinical efficacy studies mainly relying on randomized controlled trials grew rapidly; clinical safety evaluations based on real world study have been conducted; methodological researches mainly focused on study quality control deepened gradually; internationalization researches mainly on report specifications have got some breakthroughs; standardization researches based on treatment specification were strengthened gradually; the research team and talents with the characteristics of inter-disciplinary have been steadily increased. A number of high-quality research findings have been published at international well-known journals; the clinical efficacy and safety evidence of TCM has been increased; the level of clinical rational use of TCM has been improved; a large number of Chinese patent medicines with big market have been cultured. The future missions of EBCM mainly consist of four categories (scientific research, methodology and standard, platform construction and personnel training) with nine tasks. ①Carry out systematic reviews to systematically collect clinical trial reports of TCM and establish database of clinical evidence of TCM; ②Carry out evidence transformation research to lay the foundation for the development of clinical diagnosis and treatment guidelines, clinical pathways of TCM, and for the screening of basic drug list and medical insurance list, and for the policy-making relevant to TCM; ③Conduct researches to evaluate the advantages and effective regular patterns of TCM and form the evidence chain of TCM efficacy; ④Carry out researches for the safety evaluation of TCM, and provide evidence supporting the rational and safe use of TCM in clinical practice; ⑤Conduct researches on methodology of EBCM and provide method for developing high quality evidence; ⑥Carry out researches to develop standards and norms of TCM, and to form methods, standards, specifications and technical systems; ⑦Establish data management platform for evidence-based evaluation of TCM, and promote data sharing; ⑧Build international academic exchange platform to promote international cooperation and mutual recognition of EBCM research; ⑨Carry out education and popularization activities of evidence-based evaluation methods, and train undergraduate students, graduate students, clinical healthcare providers and practitioners of TCM. The development of EBCM, as it was, not only promoted the transformation of clinical research and decision-making mode of TCM, contributed to the modernization and internationalization of TCM, but also enriched the connotation of Evidence-based Medicine.

Psychometric Properties of Quality of Life Assessment Tools in Morbid Obesity: A Review of Literature

Background: Since studies have demonstrated that morbid obesity can exponentially impair quality of life, the measurement of quality of life is paramount to monitoring the effects of treatment and influences the development of clinical pathways, service provision, healthcare expenditures, and public health policy. Accordingly, clinicians, researchers, and policy makers must rely on valid instruments. Aim: This study aimed to review and critique the psychometric properties of some specific tools by COSMIN checklist and their application among morbidly obese individuals. Method: We searched PubMed, Web of Science, PsycINFO, Ovid, Elsevier, and ScienceDirect by using the keywords related to the Quality of Life Questionnaire, namely “morbid obesity”, “tool”, and “scale”, to retrieve articles published during 1989-2017. Then, the psychometric properties of the selected tools were assessed using the COSMIN checklist. Results: Most of the tools had not reported complete and desirable psychometrics properties. Demonstration of responsiveness from independent randomized controlled trials was not available in two of the eight questionnaires. These tools also did not report proper definition of interpretability. However, the data obtained by COSMIN checklist showed that Laval questionnaire is a proper scale for measuring quality of life in obese individuals, which can be recommended to researchers. Implications for Practice: Although Laval questionnaire was found a proper tool for measuring the quality of life among morbid obese patients, developing an instrument suitable for different societies with varied cultural and social characteristics is suggested because socio-cultural factors can influence the quality of life.

New drugs for Parkinson's disease: The regulatory and clinical development pathways in the United States.

Movement DisordersVolume 33, Issue 6 p. 920-927 Viewpoint New drugs for Parkinson's disease: The regulatory and clinical development pathways in the United States Karl Kieburtz MD, Karl Kieburtz MD Clintrex LLC, Sarasota, Florida, USA Department of Neurology, University of Rochester, Rochester, New York, USASearch for more papers by this authorRussell Katz MD, Russell Katz MD Clintrex LLC, Sarasota, Florida, USASearch for more papers by this authorC. Warren Olanow MD, Corresponding Author C. Warren Olanow MD cwolanow@clintrex.com Clintrex LLC, Sarasota, Florida, USA Departments of Neurology and Neuroscience, Mount Sinai School of Medicine, New York, New York, USACorrespondence to: Prof. C. Warren Olanow, Department of Neurology, Mount Sinai School of Medicine, New York, New York, USA; cwolanow@clintrex.comSearch for more papers by this author Karl Kieburtz MD, Karl Kieburtz MD Clintrex LLC, Sarasota, Florida, USA Department of Neurology, University of Rochester, Rochester, New York, USASearch for more papers by this authorRussell Katz MD, Russell Katz MD Clintrex LLC, Sarasota, Florida, USASearch for more papers by this authorC. Warren Olanow MD, Corresponding Author C. Warren Olanow MD cwolanow@clintrex.com Clintrex LLC, Sarasota, Florida, USA Departments of Neurology and Neuroscience, Mount Sinai School of Medicine, New York, New York, USACorrespondence to: Prof. C. Warren Olanow, Department of Neurology, Mount Sinai School of Medicine, New York, New York, USA; cwolanow@clintrex.comSearch for more papers by this author First published: 04 December 2017 https://doi.org/10.1002/mds.27220Citations: 8 Relevant conflicts of interest/financial disclosures: : Nothing to report. Full financial disclosures and author roles may be found in the online version of this article. This article was published online on December 14, 2017. After online publication, the address in the correspondence footnote was updated. This notice is included in the online and print versions to indicate that both have corrected on March 16, 2018. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume33, Issue6June 2018Pages 920-927 RelatedInformation

The development, implementation and evaluation of clinical pathways for chronic obstructive pulmonary disease (COPD) in Saskatchewan: protocol for an interrupted times series evaluation

BackgroundChronic obstructive pulmonary disease (COPD) has substantial economic and human costs; it is expected to be the third leading cause of death worldwide by 2030. To minimize these costs high quality guidelines have been developed. However, guidelines alone rarely result in meaningful change. One method of integrating guidelines into practice is the use of clinical pathways (CPWs). CPWs bring available evidence to a range of healthcare professionals by detailing the essential steps in care and adapting guidelines to the local context.Methods/designWe are working with local stakeholders to develop CPWs for COPD with the aims of improving care while reducing utilization. The CPWs will employ several steps including: standardizing diagnostic training, unifying components of chronic disease care, coordinating education and reconditioning programs, and ensuring care uses best practices. Further, we have worked to identify evidence-informed implementation strategies which will be tailored to the local context.We will conduct a three-year research project using an interrupted time series (ITS) design in the form of a multiple baseline approach with control groups. The CPW will be implemented in two health regions (experimental groups) and two health regions will act as controls (control groups). The experimental and control groups will each contain an urban and rural health region. Primary outcomes for the study will be quality of care operationalized using hospital readmission rates and emergency department (ED) presentation rates. Secondary outcomes will be healthcare utilization and guideline adherence, operationalized using hospital admission rates, hospital length of stay and general practitioner (GP) visits. Results will be analyzed using segmented regression analysis.DiscussionFunding has been procured from multiple stakeholders. The project has been deemed exempt from ethics review as it is a quality improvement project. Intervention implementation is expected to begin in summer of 2017.This project is expected to improve quality of care and reduce healthcare utilization. In addition it will provide evidence on the effects of CPWs in both urban and rural settings. If the CPWs are found effective we will work with all stakeholders to implement similar CPWs in surrounding health regions.Trial registrationClinicaltrials.gov (NCT03075709). Registered 8 March 2017.

Bridging the Gap in Dementia Care within an OT Primary Care Setting – The Role of Clinical Care Pathway Development

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

39.0 Implementing Clinical Pathways for Acute Behavioral Health Issues in Pediatric Medical Settings

This clinical perspective will introduce the development and implementation of clinical care pathways in the evaluation and treatment of children and adolescents presenting with acute mental health complaints to various medical settings.

Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions.

The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from the hospital, until full recovery is achieved. PSH is discussed in this consensus article with the emphasis on perioperative care coordination of patients with chronic pain conditions. Preoperative optimization can be successfully undertaken through patient evaluation, screening, and education. Many important positive implications in the PSH model, in particular for those patients with increased potential morbidity, mortality, and high-risk populations, including those with a history of substance abuse or anxiety, reflect a more modern approach to health care. Newer strategies, such as preemptive and multimodal analgesic techniques, have been demonstrated to reduce opioid consumption and to improve pain relief. Continuous catheters, ketamine, methadone, buprenorphine, and other modalities can be best delivered with the expertise of an anesthesiologist and a support team, such as an acute pain care coordinator. A physician-led PSH is a model of care that is patient-centered with the integration of care from multiple disciplines and is ideally suited for leadership from the anesthesia team. Optimum pain control will have a significant positive impact on the measures of the PSH, including lowering of complication rates, lowering of readmissions, improved patient satisfaction, reduced morbidity and mortality, and shortening of hospital stays. All stakeholders should work together and consider the PSH model to ensure the best quality of health care for patients undergoing surgery in the future. The pain management physician’s role in the postoperative period should be focused on providing optimal analgesia associated with improved patient satisfaction and outcomes that result in reduced health care costs.

Analysis of Safety-Related Regulatory Actions for New Drugs in Japan by Nature of Identified Risks.

BackgroundMechanisms underlying safety events may be heterogeneous and depend on conditions of development and marketing, including the populations studied in clinical trials and the amount of data required for approval, especially under pathways for accelerated access.ObjectiveThis study was conducted to investigate possible factors affecting the first post-marketing safety-related regulatory actions (SRRAs) after launch of new drugs in Japan.MethodsWe studied 338 new molecular entities (NMEs) approved in Japan between 2004 and 2014. We focused on three different types of SRRAs: (1) all-SRRAs (i.e. SRRAs from domestic cases and other countries), (2) domestic-SRRAs (i.e. SRRAs from domestic cases) and (3) domestic unknown-SRRAs (i.e. SRRAs of unknown risks from domestic cases). Occurrences of the three types of SRRAs were analyzed using Kaplan–Meier analysis and Cox-regression.ResultsSRRAs tended to occur sooner for NMEs launched in recent years versus those launched towards the beginning of the study period. Risk of SRRA was high for antineoplastics. Drugs for cardiovascular diseases, central nervous system, and diabetes had positive associations with all-SRRAs, but the associations were weaker with domestic-SRRAs. Domestic-SRRAs were more likely for drugs with relatively novel modes of action (MOAs). Longer lag to Japanese launch after first global launch significantly lowered SRRA risks. While most of the variables showed similar associations across the three types of SRRAs, adoption of bridging strategies showed higher risks only for domestic-SRRAs, not for all-SRRAs. FDA safety labeling changes and non-orphan priority review drugs presented higher domestic-SRRA risks. The number of adverse drug reactions (ADRs) from spontaneous reports had positive correlations with the three types of SRRAs, whereas the number from company-led surveillance showed no association.ConclusionsOur results indicated that global clinical development pathways and marketing status should be considered more seriously in implementing locally optimized pharmacovigilance activities. Caution may be needed not only for drugs with novel MOAs, but also for drugs for which local dose-finding studies have been skipped, expedited review status has been given, timing of launch is close to those in the USA and the EU, and spontaneous reports rather than company-lead surveillance suggest possible safety risks.

Using action research for workforce development and planning in integrated care

Introduction: Context – The NHS England (NHSE) Five Year Forward View (2015) aims to improve health, the quality of care and the predicted financial gap of 30 billion pounds by 2021. Strategic initiatives include prevention and self-care; enhancing primary care; efficiency measures; technology and innovation; workforce development; ‘local’, ‘joined up' services delivered ‘out of hospital’. In 2015, 29 ‘vanguard’ sites were chosen as part of the NHS New Care Models Programme to develop and test different, innovative, local models of integrated care. These models include ‘multispecialty community provider’, ‘enhanced health in care homes’, ‘acute care collaborations’,’ urgent and emergency care collaborations’ and ‘primary and acute care’ systems. The Sunderland ‘multispecialty community provider’ site is in the northeast of England (high deprivation). Risk stratification shows that 3% of the population account for 50% of the health/social care spend (frail elderly with 2 or more co-morbidities with high risk of hospital admission). Three models have been developed – Enhanced primary care; Community integrated teams (one in each of the 5 areas of the city); a Recovery at home service to facilitate early discharge and prevent re-admission. The problem – Workforce planning ‘across the system’ had not been addressed. Key issues - Historic recruitment challenges, workforce engagement, change management and governance. Practice change implemented: Action research to support the development of the workforce to deliver integrated care. Aim and theory of change: Research questions: What are the skills, knowledge and behaviours which staff need to work in integrated care to deliver high quality effective care for patients? How can current workforce development and planning approaches be improved and delivered? Action research includes phases of action and evaluation, with findings fed back into the service developmental process. It is useful when there is little evidence of best practice, where new roles/services are being developed, or there is potential for tension across services. It can also support behavioural change. The research includes documentary analysis, semi-structured interviews and focus groups. Targeted population/stakeholders: System leaders, frontline health/social care staff, patients/carers Timeline: January 2016 - April 2017 (3 phases) Highlights: Documentary analysis and scoping interviews with ‘system leaders’ in phase 1 elicited themes/challenges which have been translated into actions and are being implemented and evaluated (report Autumn 2016). Sustainability: The process/outputs will be evaluated as part of the final report Transferability: Findings are fed back to participants for validation and the New Care Models workstream to share learning and develop the evidence base. Conclusions: Phase 1 themes/challenges: • Day-to-day management • Team-working • The change process • Technology skills • Mental health skills • Patient/carer engagement and co-production • Clinical pathway development • Care co-ordination • Holistic care skills - prevention and self-care Discussion: Phase 1 results have provided a focus for the development of a workforce strategy for integrated care. Action research appears to support the engagement and development of the workforce – this will be tested further in phase 2/3. Lessons learned: To date: Building trust to share information/learning between partner organisations from the onset

EFFECTS OF IMPLEMENTING CLINICAL PATHWAY ON PAIN AND ANXIETY FOR PATIENTS UNDERGOING CARDIAC SURGERY

Background :Vulvular heart replacement surgery is an increasingly important in cardiac valve disease management .VHRS tends to be suitable for clinical pathway development because high volume , high cost of the surgery and predictable course of events that occur during hospitalization .The aim of this study was to determine the effects of implementing clinical pathway on pain and anxiety for patients undergoing cardiac surgery . Subject and methods, this is a randomized controlled design was utilized . This study was carried out in cardiothoracic surgery unit at the Mansoura University Hospital . A Purposeful sample of 50 adult patients of both sexes scheduled for vulvular heart replacement surgery was included in the study (25 clinical path group and 25 control group ). Two tools used for data collection pain scale tool and State trait anxiety inventory .The clinical pathway for cardiac surgery patients conducted in four phases : Phase one : patients assessment , Phase two :cardiac valve surgery clinical pathway establishment and jury . Phase three: implementation and tracking variances . Phase four :Evaluation .The main results of study demonstrated no statistical significant differences in basic data on admission ,.the CP group had significantly lower level of anxiety and pain than the control group before and after surgery . All of the patients in CP group had no variance from VHRS pathway which prove the preset hypothesis of the study

Improving Care for Bariatric Dental Patients in North Wales.

This paper presents the experiences of Betsi Cadwaladr University Health Board, North Wales, UK in improving facilities, access and quality of care for bariatric dental patients. It includes the multi-stakeholder audit of existing practice which informed those improvements. Public health competencies illustrated: needs assessment; development and implementation of oral health strategies; oral health improvement; development of clinical pathways; improving patient safety; clinical and public engagement; addressing inequalities.

Initiation of passive cooling at referring centre is most predictive of achieving early therapeutic hypothermia in asphyxiated newborns.

To identify factors associated with early initiation and achievement of therapeutic hypothermia (TH) in newborns with hypoxic-ischemic encephalopathy (HIE). Retrospective cohort study of newborns who received TH according to National Institute of Child Health and Human Development (NICHD) criteria in two academic level 3 Neonatal Intensive Care Units (NICU) between 2009 and 2013. All infants were transported by a neonatal transport team (NNTT). Multivariate linear regression including who initiated cooling and degree of resuscitation in the model was performed. Two hundred and seven infants were included. Waiting for advice from a tertiary care NICU was independently associated with a 50 minute delay in the median time of initiation of TH. The need for extensive resuscitation (cardiopulmonary resuscitation [CPR] or epinephrine) was independently associated with a reduction of 43 minutes in the median time to reach target core temperature. Log-transformed time to initiation of TH was associated with time to reach target core temperature (P<0.001). A doubling of time to initiation of TH corresponds to a 24% (95% CI 18% to 30%) increase in median time to reach target core temperature. Initiating passive cooling at the referring centre, before transfer, is critical to faster achievement of target core temperature in asphyxiated infants. Greater outreach education and development of clinical care pathways are needed to improve optimal delivery of TH to enhance outcome.

Newborn Bilirubin Screening for Preventing Severe Hyperbilirubinemia and Bilirubin Encephalopathy: A Rapid Review.

In this rapid review, studies were identified through the Medline database. The main outcomes of interest were severe hyperbilirubinemia and encephalopathy. A subset of articles was double screened and all articles were critically appraised using the SIGN and AMSTAR checklists. This review investigated if systems approach is likely to reduce the occurrence of severe hyperbilirubinemia. Fifty-two studies met the inclusion criteria. Included studies assessed the association between bilirubin measurement early in neonatal life and the subsequent development of severe hyperbilirubinemia and chronic bilirubin encephalopathy/kernicterus. It was observed that, highest priority should be given to (i) universal bilirubin screening programs; (ii) implementation of community and midwife practice; (iii) outreach to communities for education of prospective parents; and (iv) development of clinical pathways to monitor, evaluate and track infants with severe hyperbilirubinemia. We found substantial observational evidence that severe hyperbilirubinemia can be accurately predicted and prevented through universal bilirubin screening. So far, there is no evidence of any harm.

Depression in epilepsy

To review some aspects of the relationship between epilepsy and depression that have recently received increasing attention and may become major research topics in the near future. Epidemiological studies show that depression and suicide are, in some cases, premorbid symptoms preceding the onset of the epilepsy. Suicide is also three times more frequent in epilepsy than in the general population. Reliable screening instruments for depression and suicidality in patients with epilepsy are now available but data from real life clinical settings are needed to develop shared clinical pathways between neurology and psychiatry. Data in children with epilepsy are still limited although it is well known that, outside epilepsy, almost 50% of adult patients with mood and anxiety disorders have a previous history during childhood. Despite increasing attention to the problem, the additional stigma associated with mental health problems still represents one of the major barriers to prompt diagnosis and treatment. New studies will focus on the development of shared clinical pathways between neurology and psychiatry for mood disorders and suicide prevention. New global campaigns on the double stigma will support this process in areas where psychiatric comorbidities are still underdiagnosed and undertreated.