European Clinical Practice Guidelines Research Articles

The lipid profile of the young patient with ischemic heart disease. Do these patients meet the goals?

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitario Virgen Macarena Introduction Ischemic heart disease is becoming increasingly common in young individuals, with dyslipidemia being an important risk factor for developing acute coronary syndrome (ACS). Recently, new analytical parameters of the lipid profile have been described, which are associated with a higher cardiovascular risk. Purpose The aim of the study was to analyse characteristics, lipid profile and, whether LDL goals are achieved in young patients with ACS admitted to our Coronary Care Unit (CCU). Methods Retrospective cohort of all patients with ACS minor than 45 years admitted to a CCU between January 2010 and February 2023. The LDL goals were established according to the European clinical practice guidelines (<70 mg/dL or <55 mg/dL after 2019). Results A total of 287 patients were included, with 82.6% being male and an average age of 41 years. 77% were smokers and 9% were ex-smokers. The prevalence of classic cardiovascular risk factors at admission was as follows: dyslipidemia 105 (37%), overweight 74 (26%), obesity 70 (25%), hypertension 87 (30%), and diabetes 29 (10%). Lipid profile’s results are showed in picture 1. Smoking, gender, as well as obesity or overweight were not significantly associated with a worse lipid profile. Significant differences were also not found based on the extent of coronary involvement (analyzing the number of affected vessels or the presence of coronary occlusion) or the reason for admission (NSTEMI vs. STEMI). As for secondary prevention, 70% of patients completed the cardiac rehabilitation program. The percentage of patients who achieved the LDL goal was 62.4% at 6 months (with an average of 61 mg/dL) and 52.4% at one year (with an average of 72 mg/dL). The majority of patients (74%) who did not meet the goals at 6 months still did not achieve them at one year. A higher initial LDL-C level was associated with a lower likelihood of achieving the goals at 6 months and one year, although it did not reach statistical significance at one year (p = 0.05 and 0.08, respectively). No other predictors of success were found, although participation in a Cardiac Rehabilitation Program was associated with a non-significant trend towards goal attainment, likely due to the small sample size (45% vs. 65%, p = 0.09). Conclusion Young patients with ACS have a good short-term and long-term prognosis, which is why secondary prevention becomes particularly important. However, a significant percentage of patients still do not achieve the recommended LDL-C goals, leaving room for improvement in reducing morbidity and mortality in this population. Larger patient series are needed to gain a better understanding of this population.Table 1.Lipid profile'sLDL and Lipoprotein (a) at admission

European clinical practice guidelines for the definition, diagnosis, and treatment of oligometastatic esophagogastric cancer (OMEC-4)

IntroductionThe OligoMetastatic Esophagogastric Cancer (OMEC) project aims to provide clinical practice guidelines for the definition, diagnosis, and treatment of esophagogastric oligometastatic disease (OMD). MethodsGuidelines were developed according to AGREE II and GRADE principles. Guidelines were based on a systematic review (OMEC-1), clinical case discussions (OMEC-2), and a Delphi consensus study (OMEC-3) by 49 European expert centers for esophagogastric cancer. OMEC identified patients for whom the term OMD is considered or could be considered. Disease-free interval (DFI) was defined as the time between primary tumor treatment and detection of OMD. ResultsModerate to high quality of evidence was found (i.e. 1 randomized and 4 non-randomized phase II trials) resulting in moderate recommendations. OMD is considered in esophagogastric cancer patients with 1 organ with ≤ 3 metastases or 1 involved extra-regional lymph node station. In addition, OMD continues to be considered in patients with OMD without progression in number of metastases after systemic therapy. 18F-FDG PET/CT imaging is recommended for baseline staging and for restaging after systemic therapy when local treatment is considered. For patients with synchronous OMD or metachronous OMD and a DFI ≤ 2 years, recommended treatment consists of systemic therapy followed by restaging to assess suitability for local treatment. For patients with metachronous OMD and DFI > 2 years, upfront local treatment is additionally recommended. DiscussionThese multidisciplinary European clinical practice guidelines for the uniform definition, diagnosis and treatment of esophagogastric OMD can be used to standardize inclusion criteria in future clinical trials and to reduce variation in treatment.

SAT447 Gaps In Care: Endocrine-disrupting Chemicals And Metabolic Disease Management Guidelines

Abstract Disclosure: M. Obeid: None. A. Majid: None. R.M. Sargis: None. In recent decades, global rates of obesity, diabetes, and non-alcoholic fatty liver disease have increased substantially, imposing significant morbidity and mortality on patients and severe economic strain on healthcare systems. Discussions of modifiable risk factors responsible for metabolic dysfunction have classically centered upon the role of excess energy intake and insufficient energy expenditure. Consequently, clinical practice guidelines have largely focused upon these factors when addressing disease risk and treatment. In recent years, however, new metabolic risk factors have emerged, including exposure to endocrine-disrupting chemicals (EDCs). Because exposure to EDCs is potentially modifiable through individual action and/or public policy, we sought to understand how practice guidelines for metabolic disorders have incorporated this new knowledge into clinical care. To accomplish this, we searched PubMed for the years 2007 to 2022 for European, Asian, and American clinical practice guidelines related to obesity, diabetes, non-alcoholic fatty, dyslipidemia, chronic kidney disease, and cardiovascular disease. Each guideline was then searched by two reviewers for 83 terms related to environmental factors linked to metabolic dysfunction. Environment-related statements were then adjudicated by three reviewers for relevance. Select guidelines for non-metabolic disorders linked to environmental factors were similarly reviewed for comparison, including asthma, chronic obstructive pulmonary disease (COPD), and obstetrics/gynecology guidelines. In total, 68 guidelines and statements were systematically reviewed. While environmental risk reduction was partially addressed in COPD, asthma, and cardiovascular guidelines, those focused on obesity, diabetes, and non-alcoholic fatty liver disease did not address the contribution of EDCs or other ambient environmental factors. Across all guidelines only air pollution received substantive attention, leaving other EDCs nearly entirely neglected. A clear but inadequately considered component of the social and structural determinants of health, environmental exposures have emerged as modifiable risk factors for multiple metabolic disorders. While further work is needed, future clinical practice guidelines should incorporate clinical interventions, research initiatives, and policy recommendations to address the impact of poor environments on human metabolic health. Presentation: Saturday, June 17, 2023

A systematic assessment of the characteristics of randomized controlled trials cited by acute coronary syndrome clinical practice guidelines.

The aim of this study was to describe the methodological features of the randomized controlled trials (RCTs) cited in American and European clinical practice guidelines (CPGs) for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS). Out of 2128 non-duplicated references cited in the 2013 and 2014 American College of Cardiology/American Heart Association and 2017 and 2020 European Society of Cardiology CPGs for STEMI and NSTE-ACS, we extracted data for 407 RCTs (19.1% of total references). The majority were multicenter studies (81.8%), evaluated pharmacological interventions (63.1%), had a 2-arm (82.6%), and superiority (90.4%) design. Most RCTs (60.2%) had an active comparator, and 46.2% were funded by industry. The median observed sample size was 1001 patients (84.2% of RCTs achieved≥80% of the intended sample size). Most RCTs had a single primary outcome (90.9%), which was a composite in just over half (51.9%). Among the RCTs testing for superiority, 44.0% reported a P-value of≥0.05 for the primary outcome and 61.9% observed a risk reduction of>15%. The observed treatment effect was lower-than-expected in 67.6% of RCTs, with 34.4% having at least a 20% lower-than-expected treatment effect. The calculated post hoc statistical power was≥80% for 33.9% of cited RCTs. This analysis demonstrates that RCTs cited by CPGs can still have significant methodological issues and limitations, highlighting that a better understanding of the methodological aspects of RCTs is crucial in order to formulate recommendations relevant to clinical practice.

Consideration of sex and gender in European clinical practice guidelines in internal medicine: a systematic review protocol

IntroductionClinical practice guidelines (CPGs) are a powerful instrument to ensure evidence-based practice in clinical diagnostics and disease management. As knowledge about the impact of sex and gender on health and...

Impact of lipid lowering therapies after an acute coronary syndrome, applied through telematic consultation, in a cohort of elderly patients

Abstract Funding Acknowledgements Type of funding sources: None. Introduction After Covid-19 pandemic, telematic cardiology consultations are a reality in most developed countries. However, the impact and safety of telemedicine in the elderly population needs to be clarified. Elderly patients may need help to understand and use telemedicine effectively, being thus its benefits differential. Objetives: To assess the impact of lipid lowering therapies, after an acute coronary syndrome (ACS), applied through telematic consultation, in a cohort of elderly patients (≥70 years). Methods We performed a prospective cohort study that consecutively recruited all patients admitted to our centre with an ACS from January 1, 2020 to December 31, 2020. All patients were discharged with high-intensity statins and other currently recommended cardiovascular drugs. Lipid profile was evaluated one month after discharge. Patients were then contacted by phone, treatment was confirmed, and their lipid- lowering therapy was adjusted according to the results of the blood test. This procedure was repeated every month until LDL-c target (≤ 55 mg/dl) was achieved in accordance with current European clinical practice guidelines. Results 346 patients, 32% women, were included. Mean age was 67.3 ± 12.4 years, being 48% ≥ 70 years. Mean follow-up was 17.3 months. Patient’s main characteristics are summarized in Table 1. Comparing both subgroups, patients ≥ 70 years more frequently were women, and had past history of hypertension, diabetes, heart failure and myocardial infarction. There were no differences in clinical presentation at admission (predominantly non-ST elevation myocardial infarction). Patients ≥70 years reached the goal of LDL ≤55 mg/dl in a similar proportion to the younger subgroup (80.1% vs 82.8% p 0.051). There were no statistically significant differences in prescription between groups, with a tendency to a higher prescription of statins and ezetimibe in younger patients (62.8% vs 50.6%, p = 0.05). At follow-up, overall mortality was higher in the subgroup ≥70 years (7.8% vs 1.2%, p 0.026) at the expense of non-cardiovascular mortality (4.8% vs 0.6% p 0.013). There were no differences in cardiovascular mortality, stroke, non-fatal myocardial infarction, or non-urgent angioplasty. Conclusion Lipid lowering therapies applied through telematic consultation in a population ≥ 70 years old after an ACS is as effective and safe as in younger patients. There is however a higher mortality in this subgroup, predominantly because of non-cardiovascular causes.

Sex-related differences regarding results of lipid-lowering therapies, implemented through telematic consultation, after an acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Women are less likely than men to receive guideline-recommended therapies. There is thus little real world information on possible sex-related differences regarding results of lipid lowering therapies when guidelines are correctly applied. Understanding possible sex-related differences in lipid profile’s response to treatment after an acute coronary syndrome (ACS) might provide important information in order to improve clinical outcomes. Objetives: To assess, in a real world cohort, if there are any sex-related differences regarding results of lipid-lowering therapies, implemented through telematic consultation, after an ACS. Methods A prospective cohort study that consecutively recruited all patients admitted to our centre for an ACS from January 1, 2020 to December 31, 2020, was performed. All patients were discharged with high-intensity statins and other currently recommended cardiovascular drugs. Lipid profile was evaluated 1-month after discharge. Patients were then contacted by phone and their lipid-lowering therapy adjusted according to blood test’s results. This procedure was repeated every month until LDL-c target (≤ 55 mg/dl) was achieved in accordance with current European clinical practice guidelines. Descriptive statistics of patient characteristics at baseline and end of follow up were calculated for the overall population and then compared between men and women. We determined statistical differences between women and men using chi-squared and Student's t. Results 346 patients were included, of which 32% were women. Patient characteristics are summarized in Table 1. Women were significantly older than men (72 ± 12 vs 65 ± 12 years, p<0.001) and had more past history of hypertension and dyslipidemia. There were no differences in clinical presentation at admission (predominantly non-ST elevation myocardial infarction). Mean follow-up was 17.3 months. Even though there were no statistically significant differences in treatment prescription at discharge or after follow up, women reached the goal of LDL ≤55 mg/dl in a lower proportion to men (75.5% vs 84.3%, p 0.031) and required more time (3.69 ±2.24 vs 2.92 ± 1.95 months, p < 0.001). During follow up, total mortality was similar between groups, however women presented a higher cardiovascular mortality (4.5% vs 0.4%, p 0.014). Conclusion Our findings suggest that, applying the same guideline-recommended therapies in both women and men, there might be sex-related differences regarding lipid-lowering therapies’. Results Women reach the goal of LDL ≤55 mg/dl in a lower proportion to men and require more time. These results suggest that women might therefore need more aggressive treatment at discharge. Clinical significance of these findings is yet to be determined as our cohort is limited.

Cyanoacrylate adhesive closure in the European and American 2022 clinical practice guidelines

Over the last decade non-thermal non-tumescent (NTNT) methods of truncal reflux elimination in chronic venous disease (CVD) are becoming increasingly popular. The main NTNT modalities are mechanochemical ablation and cyanoacrylate adhesive closure (CAC). The advantages of non-thermal ablation are avoidance of tumescent anesthesia, low periprocedural pain and bruising, high patient comfort and satisfaction rates. CAC method has an additional benefit of avoiding the postprocedural compression. CAC is one of promising non-thermal ablation procedures, that leads to truncal vein occlusion and reflux elimination via endovenous delivery of n-butyl-2-cyanoacrylate. This review is aimed at assessment of the updated European and American clinical practice guidelines on CVD management, particularly the role of CAC. Current evidence shows high efficacy and safety of the CAC, its advantages regarding the periprocedural pain and ecchymoses, risk of adverse events, closure rates in the long-term, procedure and recovery time and patients’ quality of life. Therefore, along the current gold standard of varicose vein treatment – thermal ablation, the updated 2022 European and American clinical practice guidelines have significantly emphasized the role of NTNT modalities in general and CAC in particular. Specifically, the European Society for Vascular Surgeons guidelines recommend CAC for patients with great saphenous vein (GSV) incompetence when the NTNT technique is preferred. American guidelines recommend both thermal and non-thermal ablation for the patients with symptomatic axial reflux of the GSV, depending on the available expertise of the treating physician and the preference of the patient.

Do Women Physicians Accept and Follow Heart Failure Guidelines More Than Men?

Our aim was to assess the degree of acceptance of the European Clinical Practice Guidelines (CPG) on heart failure (HF) among Spanish physicians according to sex. This was a cross-sectional study, employing Google Forms, conducted by a group of HF experts from the Region of Madrid (Spain), between November 2021 and February 2022, among specialists and residents of Cardiology, Internal Medicine, and Primary Care from Spain. A total of 387 physicians-173 women (44.7%)-from 128 different centers completed the survey. Compared to men, women were significantly younger (38.2 ± 9.1years vs. 40.6 ± 11.2years; p = 0.024) and had fewer years of clinical practice (12.1 ± 8.1years vs. 14.5 ± 10.7years; p = 0.014). Briefly, women and men had a positive opinion of the guidelines and thought that implementing quadruple therapy is feasible in less than 8weeks. Women followed more frequently than men the new paradigm of "4 pillars at lowest doses" and considered more frequently the establishment of quadruple therapy before implanting a cardiac device. Although they agreed about "low blood pressure" as the major limitation for achieving quadruple therapy in heart failure with reduced ejection fraction, there were discrepancies on the second most frequent barrier, and women were more proactive when initiating SGLT2 inhibitors. In a large survey including nearly 400 doctors from all over Spain to provide real-world opinion on 2021 ESC HF Guidelines and experience with SGLT2 inhibitors, women follow more frequently the new paradigm of "4 pillars at lowest doses", consider more frequently the establishment of quadruple therapy before implanting a cardiac device, and were more proactive when initiating SGLT2 inhibitors. Further studies confirming an association of sex with a better compliance of HF guidelines are needed.

Electrocardiographic changes in patients with non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) has become a major public health problem worldwide. NAFLD is the most common chronic liver disease in developed countries and is estimated to affect 25 to 30 % of the adult population. Currently, NAFLD is considered as a multisystem disease that affects not only the liver, but also the cardiovascular system. Ultimately, these changes may be responsible for the increased cardiac morbidity and mortality associated with NAFLD. Consistent with this finding, and based on the fact that cardiovascular disease (CVD) complications often determine outcomes in patients with NAFLD, the clinical guidelines of the Russian Scientific Liver Society and the Russian Gastroenterological Association, as well as the European Clinical Practice Guidelines for the management of NAFLD recommend that a cardiovascular risk assessment should be performed in all NAFLD patients.

Qualifications, professional roles and service practices of nurses, occupational therapists and speech-language pathologists in the management of adults with oropharyngeal dysphagia: a Nordic survey

Purpose To identify the qualifications, professional roles and service practices of nurses, occupational therapists (OTs) and speech-language pathologists (SLPs) in the management of adults with oropharyngeal dysphagia (OD) in the Nordic countries. Methods A web-based survey was developed that consisted of 50 questions on respondent demographics, education, experience, roles and service practices provided for adults with OD. The survey was distributed to practicing nurses, OTs, and SLPs in five Nordic countries via professional associations, social media, online networks and snowballing. Results Data from 396 nurses, OTs and SLPs whom provided services for adults with OD revealed that the majority of respondents worked in acute care and inpatient rehabilitation facilities. Most respondents had minimal undergraduate education and practical clinical training in OD. Notable variances in roles and service practices in OD between professions and countries were found. OTs were the primary service provider for OD management in Denmark, while SLPs had this role in the other Nordic countries. Nurses were mainly involved in screening and some compensatory treatments in most Nordic countries. Limited use of evidence-based screening, non-instrumental or instrumental clinical assessments and rehabilitative therapeutic methods was evident. Conclusions Study results highlight challenges in education and training of professionals responsible for the management of adults with OD in the Nordic countries. Increased use of evidence-based assessment and exercise-based treatments to improve swallowing are warranted. Adherence to European and international clinical practice guidelines for the management of adults with OD is recommended.

Opinión sobre la guía ESC 2021 sobre insuficiencia cardiaca. Una encuesta a 387 médicos

Introduction and objectivesOur aim was to assess the degree of acceptance of the European clinical practice guidelines (CPG) on heart failure (HF) among Spanish physicians. MethodsCross-sectional study conducted via a Google form, distributed by a group of HF experts from the Community of Madrid between November 2021 and February 2022, among specialists and residents of Cardiology, Internal Medicine and Primary Care from Spain. ResultsA total of 387 doctors participated (mean age 39.5±10.3 years, 45% women), from 128 centers (60% from the Community of Madrid and 40% from other regions). The most represented specialty was Cardiology (76%), followed by Internal Medicine (20%), and Primary Care (4%); 37% of them were HF physicians. On a scale of 1 to 10, participants scored the CPG with a mean of 7.7±1.3 points. The best valued aspect was the positioning of the quadruple therapy at the same level (192, 50%), and the majority considered necessary to develop specific protocols for its implementation (353, 91%). Management (adjustment of diuretics, monitoring, antidiabetics, etc.) of sodium-glucose co-transporter type 2 inhibitors (SGLT2i) in patients with HF and reduced left ventricular ejection fraction (LVEF) was positive among the participants, but a relatively low use in other scenarios was observed. ConclusionsAlthough the new CPG on HF have been well received, the need to develop clinical protocols to facilitate its implementation is detected. SGLT2i are managed on an outpatient basis in patients with HF and reduced LVEF, but there are clinical scenarios (hospitalization and preserved LVEF) where their use can be increased.

European clinical practice guidelines on the use of chemotherapy for advanced oesophageal and gastric cancers: a critical review using the AGREE II and the AGREE-REX instruments.

To assess the methodologicalquality ofall relevant and recent European clinical practice guidelines (CPGs) for advanced oesophageal and gastric cancers, and to synthesise their recommendationson the use of chemotherapy. We searched PubMed, EMBASE, guidelines repositories, and other sources from 2010 onwards. We appraised quality using AGREE-II and AGREE-REX. 11 CPGs were included (five high, five low, and one moderate quality). Most guidelines showed deficiencies in the domain "applicability", with only three scoring above 60%. Nine did not report having sought the views and preferences of the target population. The lowest scores for AGREE-REX were itemValues and Preferences of Target Users (1.6; SD1.3), and item Values and Preferencesof Policy/Decision-Makers (1.8; SD1.7). The domain Clinical Applicability got the highest score and the domain Implementability got the lowest. An urgent area of research is how to develop credible and implementable recommendations on the clinical use of CT for advanced oesophageal and gastric cancer. PROSPERO (CRD42021236753).

A population-based study of 92 clinically recognized risk factors for heart failure: co-occurrence, prognosis and preventive potential.

AimsPrimary prevention strategies for heart failure (HF) have had limited success, possibly due to a wide range of underlying risk factors (RFs). Systematic evaluations of the prognostic burden and preventive potential across this wide range of risk factors are lacking. We aimed at estimatingevidence, prevalence and co‐occurrence for primary prevention and impact on prognosis of RFs for incident HF.Methods and resultsWe systematically reviewed trials and observational evidence of primary HF prevention across 92 putative aetiologic RFs for HF identified from US and European clinical practice guidelines. We identified 170 885 individuals aged ≥30 years with incident HF from 1997 to 2017, using linked primary and secondary care UK electronic health records (EHR) and rule‐based phenotypes (ICD‐10, Read Version 2, OPCS‐4 procedure and medication codes) for each of 92 RFs. Only 10/92 factors had high quality observational evidence for association with incident HF; 7 had effective randomized controlled trial (RCT)‐based interventions for HF prevention (RCT‐HF), and 6 for cardiovascular disease prevention, but not HF (RCT‐CVD), and the remainder had no RCT‐based preventive interventions (RCT‐0). We were able to map 91/92 risk factors to EHR using 5961 terms, and 88/91 factors were represented by at least one patient. In the 5 years prior to HF diagnosis, 44.3% had ≥4 RFs. By RCT evidence, the most common RCT‐HF RFs were hypertension (48.5%), stable angina (34.9%), unstable angina (16.8%), myocardial infarction (15.8%), and diabetes (15.1%); RCT‐CVD RFs were smoking (46.4%) and obesity (29.9%); and RCT‐0 RFs were atrial arrhythmias (17.2%), cancer (16.5%), heavy alcohol intake (14.9%). Mortality at 1 year varied across all 91 factors (lowest: pregnancy‐related hormonal disorder 4.2%; highest: phaeochromocytoma 73.7%). Among new HF cases, 28.5% had no RCT‐HF RFs and 38.6% had no RCT‐CVD RFs. 15.6% had either no RF or only RCT‐0 RFs.ConclusionOne in six individuals with HF have no recorded RFs or RFs without trials. We provide a systematic map of primary preventive opportunities across a wide range of RFs for HF, demonstrating a high burden of co‐occurrence and the need for trials tackling multiple RFs.

Factors Conditioning the Adherence to Pharmacological Prescription in Patients with Hypertension Attending Primary Healthcare Units in Quito – Ecuador

Low adherence to pharmacological treatment in patients diagnosed with hypertension is related to poor blood pressure control and an increased incidence of cardiovascular complications and deaths. A cross-sectional study was performed to determine conditioning factors towards adherence. Questionnaires and clinical evaluations were applied to 187 patients attending three first-level health units; in 130 of them laboratory tests were carried out. Diagnostic criteria were based on the European Clinical Practice Guidelines; adherence was based on the Morinsky test. 57.1% of patients had blood pressure values above the controlled threshold, and 71.1% reported non-adherence to pharmacological prescription. Factors associated whit low adherence were coexisting moderate to severe depression (OR = 2,054; CI 1,064 - 3,964), low educational level (3.75 ± 3.05 years), poor understanding of medical prescriptions (OR = 2.3 CI 1.188 - 4.477), irregular supply and limited economic access to prescribed drugs ((OR = 1.97 CI 1.08 - 3.817), and low satisfaction with the care offered at health services (OR = 2.45; CI 1.202-5.00).

Management of children and adolescents with bronchiectasis: summary of the ERS clinical practice guideline.

Bronchiectasis, characterised by chronic wet/productive cough with recurrent respiratory exacerbations and abnormal bronchial dilatation on computed tomography scans, remains an increasingly recognised but often neglected chronic pulmonary disorder in children and adolescents. An early diagnosis combined with optimal management offers the prospect, at least in some patients, of curing a condition previously considered irreversible. However, unlike in adults, until now no international paediatric guidelines existed. The recently published European Respiratory Society clinical practice guidelines for the management of children and adolescents with bronchiectasis attempts to address this clinical information gap. The guidelines were formulated by panel members comprised of experts from several relevant health fields, the European Lung Foundation and parents of children with bronchiectasis. Systematic reviews and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach guided the nature and strength of recommendations. The recommendations are grouped into clinically relevant topics: diagnosis, evaluating for underlying causes, defining exacerbations, management, systematic care, monitoring, reversibility and prevention. The guidelines seek to achieve: 1) optimal lung growth, 2) preserved lung function, 3) enhanced quality of life, 4) minimal exacerbations, 5) few or no complications, and 6) if possible, reversal of lung injury for each child/adolescent with bronchiectasis. This review presents example cases that highlight the recommendations of the clinical practice guidelines.Educational aimsThis article is intended for those involved in caring for children/adolescents with bronchiectasis. It aims to inform:Clinicians of the European Respiratory Society recommendations for the diagnosis and management of children/adolescents with bronchiectasis.Adolescents and parents of children/adolescents with bronchiectasis of these recommendations, so as to assist discussions with healthcare teams and help facilitate access to appropriate care.

2020 Russian and European clinical practice guidelines for the management of NSTEMI patients: have approaches to antithrombotic therapy been simplified?

Highlights. Prescribtion patterns of antithrombotic therapy in patients with non-ST-segment elevation acute coronary syndromes have been comapred in 2020 Russian and European clinical practice guidelines for the management of NSTEMI patients.A comparative assessment of novel approaches of antiplatelet and anticoagulant therapy recommended in 2020 European and Russian clinical practice guidelines for the management of patients with non-ST-segment elevation acute coronary syndrome is reported. In prescribing antiplatelet therapy, ESC guidelines suggest focusing attention on a more complex set of regimens to balance ischemic and hemorrhagic risks. Approaches to prescribing anticoagulant therapy do not differ in the recommendations of two medical societies. Fondaparinux has compelling advantages over other drugs regarding the combination of efficacy and safety in patients.

Metilfenidato e ADHD

Methylphenidate is the first-choice medication for the treatment of ADHD in children and adolescents. Over the past two decades, several randomised controlled trials re-peatedly showed its efficacy on both the core symptoms and the quality of life besides its tolerability in the short term. The most common adverse effects include sleep disturb-ance, nervousness, reduced appetite, weight loss, headache, elevated blood pressure and heart rate. These effects are generally mild, transient and easily manageable by clinicians. Despite the reassuring data in terms of short-term safety and tolerability, some questions still remain open with respect to the treatment effects in the long term. In the meantime it is however appropriate to continue to refer to the current European clinical practice guidelines. The paper reports treatment indications, information about the mechanism of action, the Italian available formulations and the answers to the most frequent questions for a correct clinical and pharmacological monitoring of young pa-tients.

Molecular analysis of pancreatic cystic neoplasm in routine clinical practice.

BACKGROUNDCystic pancreatic lesions consist of a wide variety of lesions that are becoming increasingly diagnosed with the growing use of imaging techniques. Of these, mucinous cysts are especially relevant due to their risk of malignancy. However, morphological findings are often suboptimal for their differentiation. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) with molecular analysis has been suggested to improve the diagnosis of pancreatic cysts.AIMTo determine the impact of molecular analysis on the detection of mucinous cysts and malignancy.METHODSAn 18-month prospective observational study of consecutive patients with pancreatic cystic lesions and an indication for EUS-FNA following European clinical practice guidelines was conducted. These cysts included those > 15 mm with unclear diagnosis, and a change in follow-up or with concerning features in which results might change clinical management. EUS-FNA with cytological, biochemical and glucose and molecular analyses with next-generation sequencing were performed in 36 pancreatic cysts. The cysts were classified as mucinous and non-mucinous by the combination of morphological, cytological and biochemical analyses when surgery was not performed. Malignancy was defined as cytology positive for malignancy, high-grade dysplasia or invasive carcinoma on surgical specimen, clinical or morphological progression, metastasis or death related to neoplastic complications during the 6-mo follow-up period. Next-generation sequencing results were compared for cyst type and malignancy.RESULTSOf the 36 lesions included, 28 (82.4%) were classified as mucinous and 6 (17.6%) as non-mucinous. Furthermore, 5 (13.9%) lesions were classified as malignant. The amount of deoxyribonucleic acid obtained was sufficient for molecular analysis in 25 (69.4%) pancreatic cysts. The amount of intracystic deoxyribonucleic acid was not statistically related to the cyst fluid volume obtained from the lesions. Analysis of KRAS and/or GNAS showed 83.33% [95% confidence interval (CI): 63.34-100] sensitivity, 60% (95%CI: 7.06-100) specificity, 88.24% (95%CI: 69.98-100) positive predictive value and 50% (95%CI: 1.66-98.34) negative predictive value (P = 0.086) for the diagnosis of mucinous cystic lesions. Mutations in KRAS and GNAS were found in 2/5 (40%) of the lesions classified as non-mucinous, thus recategorizing those lesions as mucinous neoplasms, which would have led to a modification of the follow-up plan in 8% of the cysts in which molecular analysis was successfully performed. All 4 (100%) malignant cysts in which molecular analysis could be performed had mutations in KRAS and/or GNAS, although they were not related to malignancy (P > 0.05). None of the other mutations analyzed could detect mucinous or malignant cysts with statistical significance (P > 0.05). CONCLUSIONMolecular analysis can improve the classification of pancreatic cysts as mucinous or non-mucinous. Mutations were not able to detect malignant lesions.

Serological and virological response in patients with hepatitis B virus genotype E treated with entecavir or tenofovir: a prospective study

European clinical practice guidelines (EASL) on chronic hepatitis B (CHB) recently recognized the importance of migration flows in the changing hepatitis B virus (HBV) epidemiology in low-endemic European countries. The role of different genotypes in nucleos(t)ide analogue (NA) treatment is still unknown. In the case of genotype E, which is mainly circulating in West Africa, a quantitative decrease in the level of HBsAg (qHBsAg) during treatment with entecavir (ETV) predicts a longer time to HBsAg loss when compared to genotypes A and D. We prospectively evaluated qHBsAg decline in HBeAg-negative CHB patients infected with HBV genotype E who were treated with tenofovir 245 mg (TDF) or ETV 0.5mg from 2008 to 2014. Sixty-five West African patients (58; 89.2% males) were enrolled. The median age was 29years, and the most prevalent route of transmission was familial (25; 38.5%). Median liver stiffness was 7.4kPa, HBV-DNA was 4.7LogIU/ml, and qHBsAg was 3.4LogUI/ml. According to clinical evaluation, 40 patients (61.5%) started ETV treatment, whereas 25 patients (38.5%) started TDF treatment. The decline of qHBsAg in ETV patients was significantly lower than in TDF patients after 5years of treatment (0.31 vs. 0.68LogIU/mL, p<0.001). At the same time points, a significantly higher virological non-response rate was observed in ETV patients (p<0.001). Despite the partial and non-response rates observed in the ETV group, no mutations associated with drug resistance were detected in these subjects. In genotype E infections, ETV treatment results in a significantly lower decline in qHBsAg and higher rates of virological non-response after 5years. TDF could represent the optimal choice.