Evidence-based Clinical Guidelines Research Articles

Ethical Challenges Experienced by Physicians and Nurses in Caring for Patients with COVID-19: A Qualitative Study

Background: Emerging COVID-19 pandemic has posed numerous ethical challenges to frontline healthcare professionals. Objectives: This study aimed to explain the ethical challenges experienced by physicians and nurses in caring for COVID-19 patients during the early phases of the pandemic. Methods: This qualitative study was conducted using by content analysis approach. Twenty-two semi-structured in-depth interviews were conducted with 18 physicians and nurses working in medical centers and hospitals of the public or private sectors, in Tehran, the capital of Iran, from July to October 2020. The Graneheim and Lundman approach was applied to analyze the data. MAXQDA 10 software was used to facilitate the data analysis process. Results: The ethical challenges are categorized into four categories (and 11 subcategories), including poor professional care, preference for public interests over individual care, difficult decision-making, and moral distress. Most participants experienced poor professional care, non-compassionate care, lack of family-centered care, being forced to choose, lack of emotional and anger control and coping skills, an undermined ethical climate, and emotional fatigue during the early phases of the pandemic. Conclusions: The findings indicate the attenuation of professional care and the need to develop evidence-based ethical and clinical guidelines concerning the resulting insights. In addition, devising appropriate interventions is recommended for their psycho-emotional support.

Postoperative management of total elbow arthroplasty: Results of a European survey among orthopedic surgeons.

The number of complications after total elbow arthroplasty (TEA) is high and survival rates are low compared to hip and knee arthroplasties. The most common reason for revision is aseptic loosening, which might be caused by overloading of the elbow. In an attempt to lower failure rates, current clinical practice is to restrict activities for patients with a TEA. However, postoperative management of TEA is a poorly investigated topic, as no evidence-based clinical guidelines exist and the aftercare is often surgeon-based. In this study we evaluated the current postoperative management of TEA among orthopedic surgeons. An online survey of 30 questions was sent to 635 members of the European Society for Surgery of the Shoulder and the Elbow (SECEC/ESSSE), about 10% (n = ± 64) of whom are considered dedicated elbow specialists. The questions were on characteristics of the surgeon and on the surgeon's preferred postoperative management, including items to be assessed on length of immobilization, amount of weight bearing and axial loading, instructions on lifelong activities, physiotherapy, and postoperative evaluation of the elbow. The survey was completed by 54 dedicated elbow specialists from 17 different countries. Postoperative immobilization of the elbow was advised by half of respondents when using the triceps-sparing approach (52%), and even more with the triceps-detaching approach (65%). Postoperative passive movement of the elbow was allowed in the triceps-sparing approach (91%) and in the triceps-detaching approach (87%). Most respondents gave recommendations on weight bearing (91%) or axial loading (76%) by the affected elbow, but the specification shows significant variation. The results from this survey demonstrate a wide variation in postoperative care of TEA. The lack of consensus in combination with low survival rates stresses the need for clinical guidelines. Further research should focus on creating these guidelines to improve follow-up care for TEA.

Evaluating the Inter-Reviewer Reliability and Evidentiary Grounds for Third-Party Peer-to-Peer Mandated Downgrading of Radiation Therapy Prescriptions

<h3>Purpose/Objective(s)</h3> Health plans employ utilization management strategies to control access to certain treatments in a bid to cut health care spending, frequently requiring prior authorization (PA) and subsequent peer-to-peer (P2P) discussion if the prescribed studies or treatments are not initially approved. In theory, P2P reviewers should follow current, evidence-based clinical guidelines and have knowledge of novel treatments to optimize patient care. We examine P2P determinations to downgrade prescriptions (Rx) of radiotherapy (RT) and evaluate both the evidentiary basis and internal consistency of these decisions, as applied to patients at a large academic radiation medicine department. <h3>Materials/Methods</h3> De-identified departmental billing records from 1/12/21 to 8/12/21 were used to query cases in which an Rx for RT was denied PA and ultimately downgraded on P2P in terms of RT technique, fraction number, or use of image-guided radiation therapy (IGRT). These were cross-identified with patient charts in an IRB-approved electronic medical record, and clinical details reviewed. The P2P record was searched for pair matches for each downgraded Rx (i.e., anatomic site, modality, fractionation), such that the match was approved unaltered. PubMed searches were performed for literature supporting the initial Rx in terms of control, survival, or toxicity outcomes. <h3>Results</h3> 1620 Rx were prescribed during the analyzed period, of which 697 cases were referred for PA. 123 (17.6%) of the latter were denied and referred to P2P. 31 of the 123 (25.2%) resulted in a downgraded Rx, of which 13 (41.9%) were for curative treatment, 8 (25.8%) for treatment of oligometastatic disease (OMD), and 10 (32.3%) for non-OMD palliative treatment. No Rx were downgraded for fraction number. 15 downgraded Rx (48.4%) were pair-matched with Rx that were approved unaltered on P2P. 3 (9.6%) downgraded Rx were matched with approved Rx for higher grade modality (e.g., IMRT over 3DCRT) for equivalent indications. 18 of 31 downgraded Rx (58.1%) were matched with approvals for identical or upgraded Rx, including 10 curative cases, 7 OMD cases, and 2 of 5 cases in which IGRT alone was excluded on P2P. For 17 downgraded Rx (54.8%), literature in support of the original Rx was identified, including at minimum a phase II study, a meta-analysis of > 1000 subjects, or a retrospective review with between 86 and 202 subjects. Multiple phase II studies supported all Rx for OMD that were downgraded. <h3>Conclusion</h3> Our analysis shows that more than half of treatment downgrades resulting from the P2P process can be matched with P2P approvals of the same or upgraded treatment for the same indication. We further show that published evidence could have upheld the initial prescriptions in more than half of P2P downgrades. These results suggest a high degree of inter-reviewer variability and inconsistent fidelity to evidence-based management in P2P decisions to downgrade RT Rx. Multi-institutional quality review of ultimate P2P dispositions is warranted.

Mapping the research trends and hot topics of ventricular arrhythmia: A bibliometric analysis from 2001 to 2020.

Studies of ventricular arrhythmia (VA) have drawn much scholarly attention over the past two decades. Our study aimed to assess the current situation and detect the changing research trends of VA quantitatively and qualitatively. All the information used in our statistical and bibliometric analysis were collected and summarized from papers retrieved from the Web of Science Core Collection (WoSCC) database on December 22, 2021 using certain criteria. Visual analytics were realized using CiteSpace, VOSviewer, the bibliometrix R package, and the bibliometric online analysis platform. A total of 6,897 papers (6,711 original articles, 182 proceedings papers, three book chapters, and one data paper) were published in 796 journals that concentrated on the research areas of cardiovascular and critical care medicine. The most productive country and influential institution was the USA and the Mayo Clinic, respectively. Heart Rhythm (551 articles and 8,342 local citations) published the most manuscripts. The keyword co-occurrence and co-citation network of references analyses revealed that the most popular terms were ventricular tachycardia, ventricular fibrillation, catheter ablation, implantable cardioverter defibrillator (ICD), and sudden cardiac death (SCD). Further, the burst detection analysis demonstrated that topics strongly associated with clinical prognosis, such as meta-analysis, long-term outcomes, and impact, were new concerns. Our study offers a comprehensive picture of VA research and provides profound insights into the current research status. Moreover, we show that new topics within the VA research field have focused more on prognosis and evidence-based clinical guidelines.

Practical Diabetes Care for Healthcare Professionals

This is the second edition of a paperback on the increasingly prevalent chronic condition of diabetes. The book author is a Professor of Endocrinology and Metabolism at the University of Manitoba, Canada. The author’s objective is to ‘provide the practical aspect to translate guideline dissemination into daily implementation’, acknowledging that evidence-based clinical guidelines are broad-based and therefore not practical. The target audience is all healthcare professionals involved in diabetes care. The book covers all important aspects of clinical diabetes care. The individual chapters examine the organization of diabetes care in the community and in the hospital, the use of technology in the management of diabetes, the acute and chronic complications of diabetes, and treatment considerations in the elderly and pregnancy. Each chapter starts with an abstract which summarizes key concepts and ends with a reference list of major sources. Real-life case studies are used where appropriate to enhance understanding and consolidate learning. The text is supplemented with informative tables; this includes an easy-reference 17-page table of all currently available oral and injectable medications, outlining their mechanism of action, dose, action time, benefits and disadvantages. The book can be read from cover to cover, but it is also easy to dip into to locate information of interest.

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study

BackgroundSurgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery.MethodsThis prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs.ResultsThe sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = − 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = − 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = − 0.02 SE = 0.008, p = 0.011) and 365-days (β = − 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = − 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = − 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = − 0.06, SE = 0.41, p = 0.880 EQ-5D: β = − 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect.ConclusionsNon-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

Treatment of More Than Moderate Ischemic Mitral Regurgitation in Patients Undergoing Left Ventricular Reconstruction

Objective: While evidence-based clinical guidelines recommend chordal-sparing mitral valve replacement, rather than mitral valve repair, in patients with severe ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting, there are no similar recommendations for patients undergoing left ventricular reconstruction (LVR). This study aimed to compare the clinical outcomes of mitral valve repair and replacement in patients undergoing LVR complicated by more than moderate IMR. Methods: In this single-center cohort study, a total of 74 consecutive patients who underwent LVR and mitral valve surgery (repair group: 59; replacement group: 15), during the period from March 2000 to March 2021 at Fuwai Hospital (Beijing, China) were retrospectively enrolled. Survival rates were calculated with the Kaplan-Meier method and compared using the log-rank test. Univariate Cox analysis was performed to evaluate possible confounders, followed by adjustment in multivariate analysis. The primary outcome was survival free of major adverse cardiovascular and cerebrovascular events (MACCE). Results: Median follow-up time was 59.4 months. Compared with mitral valve replacement, mitral valve repair was associated with increased risk of perioperative use of ventricular assist device (22.0% vs. 0, P = 0.045). There was no difference in overall survival (hazard ratio (HR), 1.10; 95% confidence interval (CI), 0.31–3.93; P logrank = 0.888) and MACCE-free survival (HR, 1.54; 95% CI, 0.65–3.65; P logrank = 0.319), even after multivariate Cox regression (HR, 1.35; 95% CI, 0.37–4.88; P Cox = 0.646; and HR, 1.41; 95% CI, 0.57–3.44; P Cox = 0.455, respectively). Furthermore, while no differences were observed in ejection fraction and left ventricular end-diastolic diameter on follow-up echocardiography, mitral valve repair was associated with an increased risk of recurrent mitral regurgitation (P = 0.041). Conclusions: In patients undergoing LVR complicated by more than moderate IMR, both concomitant mitral valve repair and replacement can be successfully achieved with comparable overall and MACCE-free survival outcomes; however, mitral valve replacement may be superior to mitral valve repair for persistent correction of mitral dysfunction.

An evaluation of global Chikungunya clinical management guidelines: A systematic review.

SummaryBackgroundChikungunya virus (CHIKV) has expanded its geographical reach in recent decades and is an emerging global health threat. CHIKV can cause significant morbidity and lead to chronic, debilitating arthritis/arthralgia in up to 40% of infected individuals. Prevention, early identification, and clinical management are key for improving outcomes. The aim of this review is to evaluate the quality, availability, inclusivity, and scope of evidence-based clinical management guidelines (CMG) for CHIKV globally.MethodsWe conducted a systematic review. Six databases were searched from Jan 1, 1989, to 14 Oct 2021 and grey literature until Sept 16, 2021, for CHIKV guidelines providing supportive care and treatment recommendations. Quality was assessed using the appraisal of Guidelines for Research and Evaluation tool. Findings are presented in a narrative synthesis. PROSPERO registration: CRD42020167361.Findings28 CMGs were included; 54% (15/28) were produced more than 5 years ago, and most were of low-quality (median score 2 out of 7 (range 1–7)). There were variations in the CMGs’ guidance on the management of different at-risk populations, long-term sequelae, and the prevention of disease transmission. While 54% (15/28) of CMGs recommended hospitalisation for severe cases, only 39% (11/28) provided guidance for severe disease management. Further, 46% (13/28) advocated for steroids in the chronic phase, but 18% (5/28) advised against its use.InterpretationThere was a lack of high-quality CMGs that provided supportive care and treatment guidance, which may impact patient care and outcomes. It is essential that existing guidelines are updated and adapted to provide detailed evidence-based treatment guidelines for different at-risk populations. This study also highlights a need for more research into the management of the acute and chronic phases of CHIKV infection to inform evidence-based care.FundingThe UK Foreign, Commonwealth and Development Office, Wellcome Trust [215091/Z/18/Z] and the Bill & Melinda Gates Foundation [OPP1209135].

A Multiclass Classification Model for Tooth Removal Procedures

Surprisingly little is known about tooth removal procedures. This might be due to the difficulty of gaining reliable data on these procedures. To improve our understanding of these procedures, machine learning techniques were used to design a multiclass classification model of tooth removal based on force, torque, and movement data recorded during tooth removal. A measurement setup consisting of, among others, robot technology was used to gather high-quality data on forces, torques, and movement in clinically relevant dimensions. Fresh-frozen cadavers were used to match the clinical situation as closely as possible. Clinically interpretable variables or “features” were engineered and feature selection took place to process the data. A Gaussian naive Bayes model was trained to classify tooth removal procedures. Data of 110 successful tooth removal experiments were available to train the model. Out of 75 clinically designed features, 33 were selected for the classification model. The overall accuracy of the classification model in 4 random subsamples of data was 86% in the training set and 54% in the test set. In 95% and 88%, respectively, the model correctly classified the (upper or lower) jaw and either the right class or a class of neighboring teeth. This article discusses the design and performance of a multiclass classification model for tooth removal. Despite the relatively small data set, the quality of the data was sufficient to develop a first model with reasonable performance. The results of the feature engineering, selection process, and the classification model itself can be considered a strong first step toward a better understanding of these complex procedures. It has the potential to aid in the development of evidence-based educational material and clinical guidelines in the near future.

Analyzing trends in treatment of acne vulgaris and adherence to the American Academy of Dermatology guidelines: A retrospective study

To the Editor: Acne vulgaris is a chronic inflammatory skin disease with varying treatments.1 Limited literature exists on the prescription behavior of physicians for acne. Evidence-based clinical guidelines from the American Academy of Dermatology (AAD) for acne vulgaris were published in 2016.2 Our objective was to analyze adherence to a subset of the AAD guidelines regarding antibiotic and combination therapy (Table I).

Personalized (N-of-1) Trials for Patient-Centered Treatments of Multimorbidity.

Treatment of patients who suffer from concurrent health conditions is not well served by (1) evidence-based clinical guidelines that mainly specify treatment of single conditions and (2) conventional randomized controlled trials (RCTs) that identify treatments as safe and effective on average. Clinical decision-making based on the average patient effect may be inappropriate for treatment of those with multimorbidity who experience burdens and obstacles that may be unique to their personal situation. We describe how the personalized (N-of-1) trials can be integrated with an automatic platform and virtual/remote technologies to improve patient-centered care for those living with multimorbidity. To illustrate, we present a hypothetical clinical scenario-survivors of both coronavirus disease 2019 (COVID-19) and cancer who chronically suffer from sleeplessness and fatigue. Then, we will describe how the four standard phases of conventional RCT development can be modified for personalized trials and applied to the multimorbidity clinical scenario, outline how personalized trials can be adapted and extended to compare the benefits of personalized trials versus between-subject trial design, and explain how personalized trials can address special problems associated with multimorbidity for which conventional trials are poorly suited.

Impact of the implementation of a trauma system on compliance with evidence-based clinical management guidelines in penetrating thoracic trauma.

Since 2014, a trauma system (TS) for the Provence-Alpes-Cote-d'Azur (PACA) region has been set up with protocols based on the European guidelines for the management of bleeding trauma patients. The present study aims to assess compliance with protocols in penetrating thoracic trauma on admission to a level I trauma centre and to determine whether compliance impacts morbidity and mortality. This multicentric pre-post study included all penetrating thoracic trauma patients referred to Marseille area level I centres between January 2009 and December 2019. On the basis of the European guidelines, eight objectively measurable recommendations concerning the in-hospital trauma care for the first 24h were analysed. Per-patient and per-criterion compliance rates and their impact on morbidity and mortality were evaluated before and after TS implementation. A total of 426 patients were included. No differences between the two groups (before and after 2014) were reported for demographics or injury severity. The median (interquartile range) per-patient compliance rate increased from 67% [0.50; 0.75] to 75% [0.67; 1.0] (p < 0.01) after implementation of a TS. The 30-day morbidity-mortality was, respectively, of 17% (30/173) and 13% (32/253) (p = 0.18) before and after TS implementation. A low per-patient compliance rate was associated with an increase in the 30-day morbidity-mortality rate (p < 0.01). Severity score-adjusted per-patient compliance rates were associated with decreased 30-day morbidity-mortality (odds ratio [IC 95%] = 0.98 [0.97; 0.99] p = 0.01). Implementation of a TS was associated with better compliance to European recommendations and better outcomes for severe trauma patients. These findings should encourage strict adherence to European trauma protocols to ensure the best patient outcomes.

Urological Society of Australia and New Zealand (USANZ) and Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) clinical guidelines on the management of erectile dysfunction.

These clinical practice recommendations by the Urological Society of Australia and New Zealand (USANZ) and the Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) provide evidence-based clinical guidelines on the management of erectile dysfunction (ED) in Australia. A comprehensive clinical history and a tailored physical examination are essential (Level of evidence [LoE] 3; GRADE B). Laboratory testing should include fasting glucose, lipid profile and total testosterone level (LoE 3; GRADE A). Specialised diagnostic tests are recommended in selected cases and the patient should be counselled accordingly (LoE 4; GRADE B). Lifestyle changes and optimisation of existing medical conditions should accompany all ED treatment regimens (LoE 1; GRADE A). Oral phosphodiesterase type 5 inhibitor (PDE5i) is an effective first line medical therapy (LoE 1; GRADE A). Intracavernosal injections and vacuum erection devices are recommended as second line therapy (LoE 1; GRADE B). A penile prosthesis implant can be considered in men who are medically refractory or unable to tolerate the side effects of medical therapy (LoE 4; GRADE B). Pro-erectile regenerative therapy remains largely experimental (LoE 3; GRADE B). Modification of lifestyle behaviour, management of reversible risk factors and optimisation of existing medical conditions remain pivotal, and existing standard ED therapies are often effective and safe following cardiovascular risk stratification. Caution should be exercised on the use of regenerative technology in ED due to unknown long term outcomes.

Abortion Aftercare Instructions in the United States: A Content Analysis of Patient Handouts.

At the clinical visit for abortion care, patients typically receive a handout with information about what to expect and how to care for themselves after the abortion. Published guidelines give little to no guidance regarding the content of postabortion instructions. We collected aftercare instruction handouts for first trimester procedural and medication abortion from abortion clinics throughout the United States. Instructions were coded and analyzed using conventional content analysis. Of the 84 unique aftercare handouts we received, most included information about symptoms to expect (included in 98% of procedural handouts, 97% of medication handouts), how to manage symptoms (included in 100% of procedural handouts, 100% of medication handouts), and specific behaviors to avoid (included in 94% of procedural handouts, 66% of medication handouts). The most common behavioral avoidance instructions were "pelvic rest" (included in 90% of procedural handouts, 63% of medication handouts), avoiding strenuous activity (included in 61% of procedural handouts, 29% of medication handouts), and avoiding submersion in water (included in 41% of procedural handouts, 26% of medication handouts). Handouts varied with regard to the extent and duration of specific recommendations. They also varied in tone, word choice, and other characteristics. There exists a wide range of abortion aftercare instructions throughout the United States. Inconsistency among instructions may reflect a lack of published, evidence-based clinical guidelines. Standardizing aftercare instruction handouts based on patient-oriented evidence could improve patient experience after abortion.

Abstract P009: Feasibility And Acceptability Of A Digitally-Based Blood Pressure Self-monitoring Program That Promotes Hypertension Self-management And Health Education Among Low-income Patients.

Introduction: According to evidence-based clinical guidelines, adults with hypertension should self-monitor their blood pressure regularly. We developed a remote patient monitoring (RPM) program that supports self-monitoring and promotes improved self-management among low-income patients. Hypothesis: We hypothesized that the program would have high feasibility and acceptability among patients with varying digital health literacy and at least 50% of patients would utilize their monitor at a rate required for reimbursement of the cost of the device (16 days of measurements in any 30-day period). Methods: Between 01/2022 and 05/2022, we deployed cellularly connected monitors to patients with hypertension at Family Health Centers of San Diego. Program elements included training on measurement, behavior change, SMS reminders, and physician communication. Data was monitored via a RPM platform provided by Withings. Participants completed a baseline and follow-up survey on digital health literacy and usability. We used descriptive statistics to quantify the utilization of the monitors over time and evaluate usability. Results: Patients who received blood pressure monitors (N=177) had a mean (SD) age of 55 (12.0) years and 57.6% (102 out of 177) were female. Most patients were Hispanic (71.8%, 127 out 177), spoke Spanish (62.7%, 111 out 177), and owned a smartphone (79.7%, 141 out 177). However, only 63.3% (112 out 177) had access to internet or Wi-Fi at home. The mean (SD) SBP was 136.45 mm Hg (20.5) and the mean (SD) DBP was 83.85 mm Hg (13.9). Only 20.9% (37 out of 177) of patients were able to comply with the measurement rate that would result in device cost reimbursement. This did not differ by levels of digital health literacy; with 86.2% (50 out of 58) participants having said they would recommend the monitor to others and 74.1% (43 out of 58) having said they would like to continue using the monitor in the future. Conclusion: Providing a simple and low-cost method to monitor blood pressure was feasible and acceptable to patients. However, relatively few patients were able to use the monitors at a rate that would result in device cost reimbursement. While RPM programs show promise, plans for sustaining costs among low-income patients need to be further evaluated.

Investigation of Healthcare Professionals' Knowledge of Evidence-Based Clinical Practices for Preterm Neonatal Skin Care-A Pilot Study.

Neonatal skin care practices are considered crucial for a neonate’s survival and are closely related to healthcare professionals’ (HPs) knowledge and skills in delivering scientifically valid neonatal care interventions. In this descriptive cross-sectional pilot study, conducted in 2022, we aimed to assess HPs’ basic theoretical knowledge of neonatal vernix caseosa, skin microbiota, and bathing as well as knowledge regarding evidence-based clinical practices (referred to as “clinical knowledge”) for preterm neonatal skin care. Eligible participants were neonatologists, pediatricians, obstetricians, midwives and nurses working in the Greek setting. The research instrument was an online questionnaire designed by the research team. Finally, 123 HPs took part in the study. The theoretical, clinical and total knowledge scores were all significantly associated with age, healthcare profession and the sources used for education. Participants’ theoretical and clinical knowledge scores were compared and found not to differ significantly (p = 0.566). A significant and positive correlation was found between theoretical and clinical knowledge scores. Thus, it is concluded that HPs should be updated with the latest evidence-based knowledge and clinical guidelines in order to provide neonatal skin care with high-quality standards.

Post-repair laxative management in obstetric anal sphincter injury guidelines: A narrative review.

Childbirth is a common factor which increases the risk of obstetric anal sphincter injuries (OASIS). Damage to the anal sphincters increases the risk of anal incontinence, which has a debilitating impact on the quality of life. Post-repair laxatives are prescribed in this group of women. However, there is no consensus regarding the type or frequency with which they are used, and available guidelines lack consistency and evidence to support the recommendations. The aim was to review and compare the international, national and local Australian management guidelines for recommendations regarding laxative use in women after OASIS. An online literature search of medical and nursing databases such as PubMed, Embase, MEDLINE, CINAHL, Web of Science, Scopus and Cochrane was performed between January 2000 and October 2020. Full-text articles with MeSH headings and Text Words [TW] identified guidelines in the prevention, management and care of OASIS. The search terms included 'obstetric anal sphincter injury', 'OASIS', 'perineal tear', 'postpartum continence', 'bowel injury', 'aperient', 'laxative use' and 'bulking agents'. Thirteen guidelines were included. Laxatives were recommended in most guidelines; however, there was a lack of consistency regarding the type of laxative used, frequency, dose and duration of use. Guidelines were based on historical evidence, with paucity of recently acquired data identified. There is no consensus regarding an optimal laxative regime for women who sustain an anal sphincter injury after childbirth. Further research is required to develop evidence-based robust clinical guidelines regarding laxative use in women who sustain OASIS.

Peritoneal dialysis in the modern era.

The practice and clinical outcomes of peritoneal dialysis (PD) have demonstrated significant improvement over the past 20 years. The aim of this review is to increase awareness and update healthcare professionals on current PD practice, especially with respect to patient and technique survival, patient modality selection, pathways onto PD, understanding patient experience of care and use prior to kidney transplantation. These improvements have been impacted, at least in part, by greater emphasis on shared decision-making in dialysis modality selection, the use of advanced laparoscopic techniques for PD catheter implantation, developments in PD connecting systems, glucose-sparing strategies, and modernising technology in managing automated PD patients remotely. Evidence-based clinical guidelines such as those prepared by national and international societies such as the International Society of PD have contributed to improved PD practice underpinned by a recognition of the place of continuous quality improvement processes.

Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain.

The objective of this peripheral nerve stimulation consensus guideline is to add to the current family of consensus practice guidelines and incorporate a systematic review process. The published literature was searched from relevant electronic databases, including PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from database inception to March 29, 2021. Inclusion criteria encompassed studies that described peripheral nerve stimulation in patients in terms of clinical outcomes for various pain conditions, physiological mechanism of action, surgical technique, technique of placement, and adverse events. Twenty randomized controlled trials and 33 prospective observational studies were included in the systematic review process. There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles; failed back surgery syndrome via subcutaneous peripheral field stimulation; and lower extremity neuropathic and lower extremity post-amputation pain. Evidence from current Level I studies combined with newer technologies facilitating less invasive and easier electrode placement make peripheral nerve stimulation an attractive alternative for managing patients with complex pain disorders. Peripheral nerve stimulation should be used judiciously as an adjunct for chronic and acute postoperative pain following adequate patient screening and positive diagnostic nerve block or stimulation trial.

Availability, scope and quality of monkeypox clinical management guidelines globally: a systematic review

BackgroundMonkeypox (MPX) is an important human Orthopoxvirus infection. There has been an increase in MPX cases and outbreaks in endemic and non-endemic regions in recent decades. We appraised the availability,...