Evidence-based Care Recommendations Research Articles

Feasibility and effectiveness of an evidence-based intervention bundle to improve peri-operative care of older adults

BACKGROUND Maintaining functional status is an essential therapeutic goal in peri-operative care of older adults. Although several recommendations concerning peri-operative management are available, pragmatic approaches to their sustainable implementation are lacking. OBJECTIVE Multiple evidence-based recommendations for peri-operative care of older adults were bundled into a multicomponent intervention and assessed for feasibility and effectiveness. DESIGN A quality improvement study with before–after comparison using a hybrid implementation-effectiveness approach. SETTING University Medical Centre. The trial was conducted from 2017 to 2020, follow-up was 1 week, 1 month and 6 months after surgery. PATIENTS Patients at least 65 years old were scheduled for surgery; excluded: intercranial, ophthalmological, and emergency surgery; planned postoperative stay in the intensive care unit. A total of 720 patients were eligible; 278 patients were recruited, 95 (34) of whom were female. INTERVENTIONS The intervention consisted of a set of recommended measures for peri-operative management of older patients, including pre-operative assessment and measures to manage frailty, malnutrition, polypharmacy, cognitive impairment and delirium. Patients were sequentially assigned to three groups: control (no change from usual care), transition (to implementation of the intervention) and intervention (fully implemented). MAIN OUTCOME MEASURES Feasibility was assessed by determining the level of implementation, and barriers were identified by conducting qualitative interviews with the medical staff. Intervention effectiveness was estimated by Instrumental Activities of Daily Living (IADL; Lawton and Brody, primary clinical outcome) 1 and six months postoperatively. The secondary outcomes included postoperative complications, cognitive performance, quality of life and length of hospital stay. RESULTS The implementation rate was 77%. Pre-operative IADL was 9.9/10 (range 8 to 10; SD 0.4) and 9.7/10 (6 to 10, 0.8) for the control and intervention groups, respectively. There was no statistically significant difference between the groups in IADL (0.07, 95% CI −0.23 to 0.36, P = 0.66) and 6 months after surgery (0.01, 95% CI −0.29 to 0.31, P = 0.95). CONCLUSION The implementation of evidence-based interventions to improve peri-operative care of older patients showed good feasibility in clinical routine but did not improve patients’ functional status, which was already at a high level pre-operatively. TRIAL REGISTRATION ClinicalTrials.gov, Identifier: NCT03325413

ESPEN guideline on nutrition and hydration in dementia – Update 2024

Background & aimsDementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes. MethodsThe previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process. Results40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points. ConclusionNutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

Essential Tremors: A Literature Review of Current Therapeutics.

Essential tremors (ETs) commonly manifest as involuntary shaking of the hands that disrupt daily activities. These tremors involve the central motor network of the cerebellum, thalamus, and cortical networks, leading to different clinical phenotypes. The goal of this review was to establish evidence-based recommendations for effective care and simplify decisions for those dealing with ET. For this narrative literature review, we conducted a thorough search using core keywords such as "essential tremor" and "therapy." From the 27 selected articles, relevant data were presented regarding pathophysiology, medications, and other treatment options, with necessary supplemental data such as side effects and use cases. This paper examines treatments for ET, including commonly prescribed medications such as propranolol and primidone; invasive treatments such as deep brain stimulation, focused ultrasound thalamotomy, transcranial magnetic stimulation, and some surgical methods; and non-invasive methods such as the neuromodulation technique of transcutaneous afferent patterned stimulation. Overall, this study presents a synthesized understanding of the currently available modalities for managing ETs. It is intended to guide care providers in choosing the best possible method to contain symptoms.

Polyethylene bags before cord clamping in very preterm infants: a randomised controlled trial

ObjectiveHypothermia on admission to the neonatal intensive care unit (NICU) is associated with an increased risk of death in preterm infants. There are currently no evidence-based recommendations for thermal care...

Acute care nurses' experience in providing evidence-based care for patients with laparotomy wounds: A scoping review.

To systematically search and synthesise available literature on barriers and enablers to evidence-based care for patients with laparotomy wounds reported by acute care nurses. Specifically, we focused on wound assessment, infection control techniques, wound products used, escalation of care, dressing application, documentation and holistic care. The Preferred Reporting Items for Systematic review and Meta-Analyses extension for Scoping Reviews Checklist and explanation documents directed the review. The methodology framework created by Arksey and O'Malley, updated by Levac et al., and the Joanna Briggs Institute were utilised to assist the scoping review process. Data synthesis was guided by the Theoretical Domains Framework. Six qualitative and mixed methods studies were selected for the review. Most reported barriers and enablers were mapped to knowledge, skills, beliefs about consequences, environmental context and resources and beliefs about capability domains. The main barriers were limited access to and utilisation of wound assessment tools and clinical practice guidelines for wound management and suboptimal time management skills. Inconsistent management of laparotomy wounds was related to ward culture and nurses' lack of knowledge and skills in surgical wound assessment and aseptic technique during wound encounters. The reported enablers were knowledge of multi-factorial risk factors for surgical wound recovery, valuing education and reflective practice and believing that protocols should be utilised alongside comprehensive wound assessments. Holistic wound care included patient education on the role of mobilisation and nutrition in wound healing. Acute care nurses do not routinely incorporate comprehensive, evidence-based care recommendations for laparotomy wound management. Further research on evidence-based care behaviours in managing laparotomy wounds is required. The results indicate a need for standardising the practice of laparotomy wound management while acknowledging the current challenges faced in the ward environment.

Level of episiotomy practice and its disparity among primiparous and multiparous women in Ethiopia: a systematic review and meta-analysis.

Episiotomy at the time of vaginal birth is a common lifesaving surgical procedure. In Ethiopia, several studies have been conducted concerning the proportion of episiotomy. However, its prevalence varies across these series of studies. Thus, this systematic review and meta-analysis aimed to estimate the level of episiotomy practice and its disparity among primiparous and multiparous women in Ethiopia. This systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. We systematically searched the PubMed/MEDLINE, EMBASE, Google Scholar, and Science Direct databases for studies conducted in Ethiopia focusing on episiotomy. We included all cross-sectional studies published until October 5,2022. Data were analyzed using R version 4.2.1 software. The pooled estimates with 95% confidence intervals (CIs) were presented using forest plots. A random-effects meta-analysis was conducted on extracted crude rates to calculate the national and regional pooled estimates for the country. The I-squared test and Egger's regression test were used to assess heterogeneity and publication bias, respectively. Our search yielded 390 articles. A total of 13 studies covering five administrative regions and 6,404 women who delivered vaginally were involved. The mean age of the study participants ranged from 22 to 27.7 years. The estimated overall pooled prevalence rate of episiotomy in Ethiopian women was 42.75% (95% CI: 34.97%-50.54%). In the subgroup analysis, the pooled prevalence rate of episiotomy was 61.45% (95% CI: 51.11%-71.80%) among primiparous women. Meanwhile, the pooled estimate appears to be approximately 30.47% (95% CI: 22.08%-38.85%) among multiparous women. Our findings concluded that the pooled prevalence rate of episiotomy was higher than the evidence-based WHO recommendations for optimal patient care. Parallel to this, nulliparous women had a higher episiotomy rate than multiparous women. These findings highlight the importance of continued training for labor ward staff, particularly healthcare providers who often perform the majority of deliveries.

An evidence-based quality assessment tool for ovarian cancer care delivery.

384 Background: Ovarian cancer is the fifth leading cause of cancer death among women in the United States (US). Optimizing care for patients with ovarian cancer using a systematic, guideline-concordant approach improves outcomes. However, notable gaps persist for most patients with ovarian cancer in the US. Beginning in 2018, the Association of Community Cancer Centers (ACCC) implemented a quality improvement (QI) initiative in community and academic cancer centers to address care gaps. From this work, our expert steering committee published a quality document to inform evidence based ovarian cancer care delivery. Methods: In Phase II of this project we used the quality document to inform a qualitative baseline self-assessment and development of four six-month QI initiatives at cancer centers in the US. Based on this work, we developed a quality assessment tool to aid cancer centers in performing QI needs-assessments using the ovarian cancer quality document. The assessment tool applies evidence-based care recommendations in key areas identified by our multidisciplinary steering committee comprised of experts in ovarian cancer care. Results: The assessment tool includes a series of program-level questions and addresses seven key domains: 1. Care coordination and patient education, 2. Prevention and screening, 3. Diagnosis and initial management, 4. Treatment planning, 5. Disease surveillance, 6. Equity in care, and 7. Quality of life. Each domain has between two and seven key recommendations identified. Sites rate themselves on a four-point scale (1-unsatisfactory, 2-needs improvement, 3-acceptable, 4-good) for each key recommendation. Each key recommendation is given equal weight, and a combined score from 0-100 is calculated for each of the seven domains. The tool includes a macro-enabled spreadsheet that makes necessary calculations and provides an overall score, domain-specific sub-scores, and a list of key recommendations that received low ratings. The tool is to be used by clinical sites to self-assess the quality of ovarian cancer care currently provided at their cancer program and serves as a needs assessment. It is recommended that the site team performs the self-assessment in the context of a facilitated half-day multidisciplinary team meeting. After the self-assessment, sites are encouraged to develop QI initiatives to address the gaps identified using the format and structure we have previously described. Conclusions: The QI Assessment tool provides an important resource for cancer centers to conduct needs assessments in key areas of ovarian cancer care. The needs assessment can be used to inform the implementation of program-specific QI initiatives to elevate quality care delivery.

Cannabis Use Patterns among Patients with Early-Stage Breast Cancer in a Large Multicenter Cohort from a State with Legalized Adult Non-Medical Cannabis

Cannabis use among patients with cancer is an area of great interest given its widespread acceptance despite the lack of supporting clinical data. The absence of data limits the understanding of potential clinical benefits of cannabis and the ability of providers to deliver evidence-based recommendations for patient care. We explored cannabis use patterns in patients with early-stage breast cancer in a large multicenter cohort in a state with legalized adult non-medical cannabis. Initial questions about cannabis use history and frequency were introduced in Michigan Radiation Oncology Quality Consortium (MROQC) breast cancer patient surveys on 2/1/2020 for female patients receiving radiation after lumpectomy for non-metastatic breast cancer. Expanded questions were introduced on 6/28/2022 to assess mode of administration, active ingredient, and reason for use. Summary statistics were generated. A multivariable model using logistic regression identified patient characteristics associated with cannabis use. Among 3948 eligible patients, 2738 (69.35%) completed survey questions, and 2462/2738 (89.9%) completed the initial question on cannabis use. Among those, 364/2462 (14.8%) noted cannabis use in the last 30 days, 588 (23.9%) noted remote use (>30 days ago), 1462 (59.4%) reported never having used cannabis, 44 (1.8%) preferred not to answer cannabis use questions, and 4 (0.4%) did not provide use history. Younger age [age <50 vs 60-70, OR 2.5 (95% CI 1.65, 3.79) p<0.001)], Hispanic ethnicity [OR 2.20 (95% CI 1.06, 4.56) p = 0.03], history of smoking [OR 2.56 (95% CI 1.88, 3.48) p<0.001], current smoking [OR 4.70 (95% CI 3.22, 6.86) p<0.001)], and prior chemotherapy [OR 1.40 (95% CI 1.00, 1.96) p = 0.05] predicted recent cannabis use in a multivariable model. Of the 364 patients endorsing cannabis use in the last 30 days, 89 (24.5%), 72 (19.8%), 29 (8.0%), 66 (18.1%), 30 (8.2%), and 78 (21.4%) reported using cannabis 1-2 days, 3-5 days, 6-9 days, 10-19 days, 20-29 days, and all 30 days, respectively. The most common modes of administration among 76 individuals who responded to the expanded questionnaire to date were oral (39.4%), smoking (30.3%), and topical (10.5%). The products used contained tetrahydrocannabinol (THC; 26.3%), cannabidiol (CBD; 19.7%), balanced levels of THC and CBD (19.7%), or active ingredients that were unknown to the patient (34.2%). Patients frequently endorsed cannabis use for insomnia, anxiety, and pain. Many patients with early-stage breast cancer are using cannabis. Younger age, Hispanic ethnicity, smoking, and chemotherapy history are predictors of cannabis use. Patients are often unaware of the active ingredients in the products that they use, suggesting an important role for patient education and a need to equip providers to advise patients in their care.

Evidence-Based Consensus Recommendations for Skin Care in Healthy, Full-Term Neonates in India.

Neonatal skin care practices guided by personal experience and preferences might be substantially different across different hospital settings. The aim of this consensus recommendation is to provide clinical practice guidance to healthcare practitioners on evidence-based neonatal skin care practices from delivery-to-discharge, in hospital settings. A Scientific Advisory Board meeting on "Evidence-based Neonatal Skin Care Practices and Protocols" was held in December 2020 with an expert panel comprising neonatologists, pediatricians, obstetricians and gynecologists and pediatric dermatologist. Comprehensive literature search was performed up to 23 March 2021 using PubMed and Google Scholar to retrieve relevant evidence. Recommendations were developed on critical aspects of skin care in healthy full-term neonates including cleansing at birth, skin-to-skin care, cord care, diaper area care, initial and routine bathing, cleansers and emollients use, and criteria to choose appropriate skin care products. Recommendations include inclusion of skin assessment in routine neonatal care, first bath timing after cardio-respiratory and thermal stabilization, 6-24 hours after birth; bathing with water alone or adding a mild liquid cleanser could be considered appropriate as it does not impact the developing skin barrier; use of emollients is recommended for neonates with higher risk of development of eczema to maintain and enhance skin barrier function and integrity; and inclusion of skin care advice in neonatal discharge checklist. Importance of rigorous quality control, high-quality clinical trials for assessment of baby products, usage of products that are formulated appropriately for newborns, and full label transparency for baby products were highlighted. The panel identified gaps in literature and discussed the scope for future research. These recommendations may help to standardize evidence-based skin care for healthy full-term neonates in Indian hospital settings to improve the quality of care that neonates receive in hospital and facilitate improvement in overall neonatal health outcomes.

Effects of the COVID-19 Pandemic on Primary Health Care for Chronic Conditions in Canada: Protocol for a Retrospective Pre-Post Study Using National Practice-Based Research Network Data.

Since the COVID-19 pandemic began, there have been concerns that interruptions to the health care system may have led to changes in primary care, especially for care of chronic conditions such as diabetes and heart failure. Such changes may have longer term implications for population health. This study aims to describe the impacts of the COVID-19 pandemic on indicators of primary care access, comprehensiveness, and appropriateness among adult patients, as well as on specific indictors of chronic conditions. Additionally, this study aims to determine whether any identified changes were associated with patient sociodemographic characteristics and multimorbidity. This is a retrospective, single-arm, pre-post study using Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data. CPCSSN is a research network supported by a primary care electronic medical record database, comprising over 1500 physicians and nearly 2 million patients. We are examining changes in care (eg, frequency of contacts, laboratory tests and investigations, referrals, medications prescribed, etc) among adults. We will also examine indicators specific to evidence-based recommendations for care in patients with diabetes and those with heart failure. We will compare rates of outcomes during key periods of the pandemic between March 13, 2020, and December 31, 2022, with equal time periods before the pandemic. Differences will be examined among specific subgroups of adults, including by decade of age, number of comorbidities, and socioeconomic status. Regression models appropriate to outcome distributions will be used to estimate changes, adjusting for potential confounders. This analysis is part of a mixed-methods study with a qualitative component investigating how patients with diabetes with or without concurrent heart failure perceived the impact of the pandemic on access to primary care and health care-related decisions. This study was approved by the Hamilton Integrated Research Ethics Board (14782-C). The start date of this study was October 5, 2022, and the prospective end date is January 31, 2024. As of May 2023, the study cohort (n=875,934) is defined, data cleaning is complete, and exploratory analyses have begun. Extended analyses using 2022 data are planned once the new data becomes available. We will disseminate results through peer-reviewed publications and academic conference, as well as creating evidence briefs, infographics, and a video for policy maker and patient audiences. This study will investigate whether the COVID-19 pandemic has resulted in changes in the provision of primary care in Canada and whether these potential changes have led to gaps in care. This study will also identify patient-level characteristics associated with changes in care patterns across the COVID-19 pandemic. Indicators specific to chronic conditions, namely diabetes and heart failure, will also be explored to determine whether there were changes in care of these conditions. ClinicalTrials.gov NCT05813652; https://clinicaltrials.gov/ct2/show/NCT05813652. RR1-10.2196/49131.

Care after premenopausal risk-reducing salpingo-oophorectomy in high-risk women: Scoping review and international consensus recommendations.

Women at high inherited risk of ovarian cancer are offered risk-reducing salpingo-oophorectomy (RRSO) from age 35 to 45 years. Although potentially life-saving, RRSO may induce symptoms that negatively affect quality of life and impair long-term health. Clinical care following RRSO is often suboptimal. This scoping review describes how RRSO affects short- and long-term health and provides evidence-based international consensus recommendations for care from preoperative counselling to long-term disease prevention. This includes the efficacy and safety of hormonal and non-hormonal treatments for vasomotor symptoms, sleep disturbance and sexual dysfunction and effective approaches to prevent bone and cardiovascular disease.

Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery.

The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.

Pharmacist-provider collaborative visits after hospital discharge in a comprehensive acute kidney injury survivor model

BackgroundPostdischarge follow-up in primary care is an opportunity for pharmacists to re-evaluate medication use in acute kidney injury (AKI) survivors. Of the emerging AKI survivor care models described in literature, only one involved a pharmacist with limited detail about the direct impact. ObjectiveThis study aimed to describe pharmacist contributions to a comprehensive postdischarge AKI survivorship program in primary care (the AKI in Care Transitions [ACT] program). MethodsThe ACT program was piloted from May to December of 2021 at Mayo Clinic as a bundled care strategy for patients who survived an episode of AKI and were discharged home without the need for hemodialysis. Patients received education and care coordination from nurses before discharge and later completed postdischarge laboratory assessment and clinician follow-up in primary care. During the follow-up encounter, patients completed a 30-minute comprehensive medication management visit with a pharmacist focusing on AKI survivorship considerations. Medication therapy recommendations were communicated to a collaborating primary care provider (PCP) before a separate 30-minute visit with the patient. PCPs had access to clinical decision support with evidence-based post-AKI care recommendations. Medication-related issues were summarized descriptively. ResultsPharmacists made 28 medication therapy recommendations (median 3 per patient, interquartile range 2-3) and identified 14 medication discrepancies for the 11 patients who completed the pilot program, and 86% of the medication therapy recommendations were acted on by the PCP within 7 days. Six recommendations were made to initiate renoprotective medications, and 5 were acted on (83%). ConclusionDuring the pilot phase of a multifaceted transitional care program for AKI survivors, pharmacists’ successfully identified and addressed multiple medication therapy problems, including for renally active drugs. These results demonstrate the potential for pharmacist-provider collaborative visits in primary care to improve safe and effective medication use in AKI survivors.

Intrinsic factors contributing to elevated intra-abdominal pressure

Pelvic floor disorders affect 24% of US women, and elevated intra-abdominal pressure may cause pelvic injury through musculoskeletal strain. Activity restrictions meant to reduce pelvic strain after traumatic events, such as childbirth, have shown little benefit to patients. Reported high variability in abdominal pressure suggests that technique plays a substantial role in pressure generation. Understanding these techniques could inform evidence-based recommendations for protective pelvic care. We hypothesized use of a motion-capture methodology could identify four major contributors to elevated pressure: gravity, acceleration, abdominal muscle contraction, and respiration. Twelve women completed nineteen activities while instrumented for whole body motion capture, abdominal pressure, hip acceleration, and respiration volume. Correlation and partial least squares regression were utilized to determine primary technique factors that increase abdominal pressure. The partial least squares model identified two principal components that explained 59.63% of relative intra-abdominal pressure variability. The first component was primarily loaded by hip acceleration and relative respiration volume, and the second component was primarily loaded by flexion moments of the abdomen and thorax. While reducing abdominal muscle use has been a primary strategy in protective pelvic floor care, the influence of hip acceleration and breathing patterns should be considered with similar importance in future work.

Engaging continuing medical education in evaluating knowledge gaps and preferences in advanced BRAF+ melanoma.

e23007 Background: Given the rapid evolution of treatments for advanced melanoma, oncology providers are challenged to stay current on evidence-based recommendations for optimal patient care. Integrating practice-based polling into continuing medical education (CME) activities is a proven way to increase engagement, address knowledge gaps, and assess attitudes on specific topics. Methods: We provided a CME activity designed to educate oncology and dermatology providers on the latest advances regarding the management of advanced BRAFmut+ melanoma. Interspersed engagement opportunities further assessed practice preferences and elucidated persisting educational needs. The CE activity was available for credit from December 31, 2020 to December 30, 2021. Results: 305 medical oncology or dermatology providers who each see an average of 25 patients with melanoma per month participated. These providers scored an average 38% on pretest topics related to the use of triple therapy and patient and/or tumor characteristics that guide clinical decision-making. Post-learning, providers scored 84%, highlighting the impact of the education on knowledge gaps. Notably, while 51% of these providers indicated that they were guessing on the pre-test, the percentage of those who were confident and correct on the post-test rose from 3% to 28%, demonstrating a rise in confidence among participants. While 50% of participants noted a positive perception of triple therapy (BRAF inhibitor + MEK inhibitor + anti-PD1) in the front-line setting, case-based polling questions showed that providers lack consensus regarding the use of combinations of treatments in other clinical scenarios. While 45% would recommend triple therapy in the first-line setting, dual checkpoint inhibitor (CPI)-based treatment is preferred after progression on a first-line CPI or dual-targeted therapy. Conclusions: CME is a useful method to address knowledge gaps regarding evolving treatment options. As data regarding the use of triple therapy for patients with BRAF+ melanoma emerges, oncology and dermatology providers will require further education on how to apply these options in practice.[Table: see text]

Emollients to Prevent Eczema in High-Risk Infants: Integrative Review.

Searches were conducted in September 2021 in PubMed, CINAHL, Cochrane Library, and Web of Science using key word search terms dermatitis, atopic, emollients, petrolatum, and infant, newborn. Inclusion criteria were articles written in English published between 2010 and 2021 that tested emollients in high-risk infants and measured the development of AD. Eight primary research articles were included. Six studies were limited by small sample sizes, short-term application of emollients, and short-term follow-up. These studies generated inconclusive results. Two large randomized controlled trials (RCTs) with a combined sample of 3,791 infants found no evidence that early, regular use of emollients prevents AD among high-risk infants. Findings from two high-quality RCTs indicate that clinicians should not recommend use of emollients to prevent AD. Clinicians may provide evidence-based recommendations for infant skin care, including bathe with water or a combination of water and liquid cleanser formulated for infants, and avoid soaps. Products applied to skin should be free of scent and contact allergens. Petroleum jelly or mineral oil is appropriate to moisturize infants' skin as needed.

Placement of Nasogastric Feeding Tube and Postinsertion Care Review

Insertion and postinsertion care of enteral nasogastric feeding tubes are common procedures in the United States, with more than 1.2 million temporary nasogastric feeding tubes inserted annually. Although there are some evidence-based practice guidelines and recommendations for care of these tubes, variation in practice still exists. Additional research is needed to determine the best methodology for insertion and confirmation of nasogastric feeding tubes. Routine competency and training on feeding tube insertion, enteral nutrition, and postinsertion care is crucial to prevent patient safety events. Variable results have been reported with different technologies; however, radiographic confirmation remains the criterion standard. It is important that health care institutions develop standardized procedures for insertion and confirmation on the basis of evidence-based practices to minimize risks and complications from temporary nasogastric feeding tubes.

ESPEN practical guideline: Clinical nutrition and hydration in geriatrics

Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats. To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons. This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process. We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counselling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach. A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline Revision: Reduction Mammaplasty.

A multidisciplinary work group involving stakeholders from various backgrounds and societies convened to revise the guideline for reduction mammaplasty. The goal was to develop evidence-based patient care recommendations using the new American Society of Plastic Surgeons guideline methodology. The work group prioritized reviewing the evidence around the need for surgery as first-line treatment, regardless of resection weight or volume. Other factors evaluated included the need for drains, the need for postoperative oral antibiotics, risk factors that increase complications, a comparison in outcomes between the two most popular techniques (inferior and superomedial), the impact of local anesthetic on narcotic use and other nonnarcotic pain management strategies, the use of epinephrine, and the need for specimen pathology. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development and Evaluation methodology). Evidence-based recommendations were made and strength was determined based on the level of evidence and the assessment of benefits and harms.

American College of Nurse-Midwives Clinical Bulletin Number 18: Induction of Labor.

Induction of labor is an increasingly common component of intrapartum care in the United States. This rise is fueled by a nationwide escalation in both medically indicated and elective inductions at or beyond term, supported by recent research showing some benefits of induction over expectant management. However, induction of labor medicalizes the birth experience and may lead to a complex cascade of interventions. The purpose of this Clinical Bulletin is twofold: (1) to guide clinicians on the use of person-centered decision-making when discussing induction of labor and (2) to review evidence-based practice recommendations for intrapartum midwifery care during labor induction.