Evidence-based Guidelines For Management Research Articles

Effect of Antibiotic Prescription Audit and Feedback on Antibiotic Prescribing in Primary Care

Antibiotics are commonly prescribed in primary care, increasing the risk of antimicrobial resistance in the population. To investigate the effect of quarterly audit and feedback on antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates. This pragmatic randomized clinical trial was conducted from January 1, 2018, to December 31, 2019, among 3426 registered primary care physicians and pediatricians in single or small practices in Switzerland who were among the top 75% prescribers of antibiotics. Intention-to-treat analysis was performed using analysis of covariance models and conducted from September 1, 2021, to January 31, 2022. Primary care physicians were randomized in a 1:1 fashion to undergo quarterly antibiotic prescribing audit and feedback with peer benchmarking vs no intervention for 2 years, with 2017 used as the baseline year. Anonymized patient-level claims data from 3 health insurers serving roughly 50% of insurees in Switzerland were used for audit and feedback. The intervention group also received evidence-based guidelines for respiratory tract and urinary tract infection management and community antibiotic resistance information. Physicians in the intervention group were blinded regarding the nature of the trial, and physicians in the control group were not informed of the trial. The claims data used for audit and feedback were analyzed to assess outcomes. Primary outcome was the antibiotic prescribing rate per 100 consultations during the second year of the intervention. Secondary end points included overall antibiotic use in the first year and over 2 years, use of quinolones and oral cephalosporins, all-cause hospitalizations, and antibiotic use in 3 age groups. A total of 3426 physicians were randomized to the intervention (n = 1713) and control groups (n = 1713) serving 629 825 and 622 344 patients, respectively, with a total of 4 790 525 consultations in the baseline year of 2017. In the entire cohort, a 4.2% (95% CI, 3.9%-4.6%) relative increase in the antibiotic prescribing rate was noted during the second year of the intervention compared with 2017. In the intervention group, the median annual antibiotic prescribing rate per 100 consultations was 8.2 (IQR, 6.1-11.4) in the second year of the intervention and was 8.4 (IQR, 6.0-11.8) in the control group. Relative to the overall increase, a -0.1% (95% CI, -1.2% to 1.0%) lower antibiotic prescribing rate per 100 consultations was found in the intervention group compared with the control group. No relevant reductions in specific antibiotic prescribing rates were noted between groups except for quinolones in the second year of the intervention (-0.9% [95% CI, -1.5% to -0.4%]). This randomized clinical trial found that quarterly personalized antibiotic prescribing audit and feedback with peer benchmarking did not reduce antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates. ClinicalTrials.gov Identifier: NCT03379194.

Management of silicone granuloma: A systematic review

Management of silicone granuloma: A systematic review

Heart failure in systemic right ventricle: Mechanisms and therapeutic options.

d-loop transposition of the great arteries (d-TGA) and congenitally corrected transposition of the great arteries (cc-TGA) feature a right ventricle attempting to sustain the systemic circulation. A systemic right ventricle (sRV) cannot support cardiac output in the long run, eventually decompensating and causing heart failure. The burden of d-TGA patients with previous atrial switch repair and cc-TGA patients with heart failure will only increase in the coming years due to the aging adult congenital heart disease population and improvements in the management of advanced heart failure. Clinical data still lags behind in developing evidence-based guidelines for risk stratification and management of sRV patients, and clinical trials for heart failure in these patients are underrepresented. Recent studies have provided foundational data for the commencement of robust clinical trials in d-TGA and cc-TGA patients. Further insights into the multifactorial nature of sRV failure can only be provided by the results of such studies. This review discusses the mechanisms of heart failure in sRV patients with biventricular circulation and how these mediators may be targeted clinically to alleviate sRV failure.

Clinical practice guideline adaptation for risk-based caries management in 18–55 year-old Iranian adults

PurposeTo adapt an evidence-based clinical practice guideline (CPG) for risk-based management of caries in 18–55 year-old Iranian adults.MethodsA multidisciplinary adaptation team reviewed evidence-based guidelines such as the NICE, SIGN, and ADA according to the defined clinical questions. In addition, databases such as the PubMed and Google Scholar were searched and CPGs were screened and appraised using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) tool. Clinical scenarios were developed and their level of evidence, clinical advantage and adaptability were assessed. Following a two-round ranking by experts, the final recommendations were selected using the RAND-UCLA appropriateness method.ResultsOf 17 CPGs, 5 were selected as the source guidelines for adaptation. To assess the risk of caries in the adult population, reduced Cariogram (without saliva tests) and CAMBRA were suggested as diagnostic tools. In addition, 53 risk-based recommendations on the preventive care (including the use of fluoride toothpaste, fluoride, and chlorhexidine mouthwash, at home and in-office fluoride gel, fluoride varnish, mouth buffering, and sealant), operative intervention threshold, and follow-up interval were adapted for Iranian adults.ConclusionsA guideline was adapted for risk-based management of dental caries in Iranian adults. This helps local dentists in decision making and promoting oral health of adults. Further research is needed to assess the external validity and feasibility of the adapted guideline in the Iranian population.

ІДІОПАТИЧНИЙ ЛЕГЕНЕВИЙ ФІБРОЗ І ПРОГРЕСУЮЧИЙ ЛЕГЕНЕВИЙ ФІБРОЗ У ДОРОСЛИХ: АДАПТОВАНА КЛІНІЧНА НАСТАНОВА, ЗАСНОВАНА НА ДОКАЗАХ (ПРОЕКТ)

In 2000 American Thoracic Society (ATS) and European Respiratory Society (ERS) published first international statement on diagnosis and treatment of idiopathic pulmonary fibrosis (IPF) — American Thoracic Society, European Respiratory Society. Idiopathic pulmonary fibrosis: diagnosis and treatment. International consensus statement. In 2011 there was published new statement on diagnosis and treatment of IPF, approved by ATS, ERS, Japan Respiratory Society (JRS) and Latin American Thoracic Society (ALAT) — An Official ATS/ERS/JRS/AL: Idiopathic Pulmonary Fibrosis: Evidence-based Guidelines for Diagnosis and Management, in 2015 — section «Treatment», and in 2018 — section «Diagnosis» an update. It is known, that in part of the patients with such an insterstitial lung disease (ILD) as idiopathic nonspecific interstitial pneumonia, systemic sclerosis, pneumoconiosis, chronic hypersensitivity pneumonitis, sarcoidosis, lung fibrosis may acquire a progressive uncontrolled character with combination of symptoms described as Progressive Pulmonary Fibrosis (PPF). Besides, in recent years there have been published data on successful use of antifibrotic therapy in several fibrosing ILD, other than IPF (INBUILD, SENSCIS studies). This has required the change of the treatment paradigm in favor for a unified approach to antifibrotic therapy. This was a rationale for an inclusion of other ILD manifested as PPF into the list of indications for use of antifibrotic therapy. To comply with this novelty the experts of ATS, ERS, JRS and ALAT in May 2022 published new statement An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline. Idiopathic Pulmonary Fibrosis (an Update) and Progressive Pulmonary Fibrosis in Adults. In this document alongside with partial update of IPF diagnosis and treatment principles, there have been presented a definition, diagnosis criteria and recommendations for treatment of PPF in other ILD. In summary, «An Official ATS/ERS/JRS/ALAT Statement: Idiopathic Pulmonary Fibrosis: Evidence-based Guidelines for Diagnosis and Management» (2011) and its updated sections «An Official ATS/ERS/JRS / ALAT Clinical Practice Guideline: Treatment of Idiopathic Pulmonary Fibrosis. An Update of the 2011 Clinical Practice Guideline» (2015), “Diagnosis of Idiopathic Pulmonary Fibrosis: An Official ATS/ERS/JRS/ ALAT Clinical Practice Guideline» (2018) and Idiopathic Pulmonary Fibrosis (an Update) and Progressive Pulmonary Fibrosis in Adults were used a the prototype documents for creation of Adapted clinical guideline «Idiopathic pulmonary fibrosis and progressive pulmonary fibrosis in adults». Key words: idiopathic pulmonary fibrosis, progressive pulmonary fibrosis, definiition, diagnosis, treatment, antifibrotic therapy.

Malawian critical care nurses' views on the implementation of an educational intervention to enhance sustained use of an evidence-based endotracheal tube cuff pressure management guideline: A survey study.

Evidence-based guidelines can assist critical care nurses in promoting best practices, including those related to endotracheal tube cuff pressure management. However, these guidelines require tailored strategies to enhance their implementation, uptake, and sustained use in practice. To evaluate Malawian critical care nurses' views on the implementation of an endotracheal tube cuff pressure management guideline to enhance sustained guideline use. An explorative-descriptive survey design was employed, using a questionnaire with closed- and open-ended questions that was distributed after implementation of an educational intervention based on an endotracheal tube cuff pressure management guideline. The questionnaire had a Cronbach's alpha score of 0.85. A total of 47 nurses working in four public and two private hospital intensive care units in Malawi participated. Quantitative findings showed that the majority of the participants (92%) indicated that the strategies used for the group that received the full intervention including both active (monitoring visits) and passive (a half-day educational session using a PowerPoint presentation, and a printed guideline and algorithm) strategies (intervention 1 group) were useful, clear and applicable and enhanced implementation of the guideline. These results were statistically significant (mean (standard deviation) 1.86 (0.84); t=6.07; p<0.0005). Qualitative data revealed three major themes related to recommendations for uptake and sustained use of the guideline in nursing practice: the guideline needs to be translated, updated, and made available to ICU staff; implementation strategies (continuous supervision and follow-up); and facilitating factors for successful implementation (education and training on guideline content, resources, and commitment to best practices). The study highlighted that although the implementation strategies used were positively received by participants, they need to be further tailored to their context to enhance guideline uptake and sustained use in practice. Further study is required to ensure that tailored implementation strategies facilitate guideline uptake and sustained use, specifically in resource-constrained contexts. The study findings can be used by nurses and academics when developing educational interventions for critical care units to enhance implementation of guidelines in this context.

Management and outcomes of spinal tuberculosis in Africa: a scoping review protocol

AbstractBackgroundSpinal tuberculosis (TB) remains a major public health challenge in Africa, where 85% of the global deaths from TB is recorded. Patients with spinal TB have a high tendency to develop permanent disability, with significant financial costs. Most patients with spinal TB from Africa are unable to receive timely and effective intervention due to several socio-economic factors, deplorable healthcare infrastructure and inadequate specialized workforce. In addition, there is a lack of contextually appropriate evidence-based guidelines for management of this potentially debilitating but treatable condition. This scoping review protocol outlines how the authors aim to investigate the available evidence on the management and outcome of spinal TB in Africa.MethodsAJOL, Embase, Pubmed/Medline, Google Scholar and Conchrane will be searched for articles published on the management and outcome of TB since the inception of the database. All patients from any of the 54 African countries will be included regardless of the socio-demographics.ResultsThe primary outcomes will include the available treatment modalities and the clinical outcomes among patients managed for spinal TB in Africa. Secondary outcomes will include the epidemiology of spinal TB in Africa, information on the availability of diagnostic tools and the challenges faced in the management of spinal TB in Africa, including delays in treatment.DiscussionAnalysis of the outcomes and prognostic indicators will allow for a comparison of patient cohorts and the effectiveness of the different treatment modalities employed across Africa. This scoping review will be the first to address this research question.

The first reported case of factor X deficiency in a Filipino child – case study

Abstract Factor X (FX) deficiency is an extremely rare inherited bleeding disorder affecting one in 1,000,000 people. According to the most recent published census of the World Hemophilia Federation, to date there is no reported case of FX deficiency in the Philippines. Rare disorders like FX deficiency often go unrecognised or misdiagnosed. Here, we report the first case of FX deficiency in a Filipino child. A two-month-old male child with consanguinity was referred to our hospital due to bleeding episodes. On the third day of life, he had haematomas to the cervical area and upper extremities, and spontaneous bleeding of the umbilical cord was noted. Initial workup showed prolonged PT and aPTT. Factor deficiencies including FVIII and FIX were considered, however assays were normal. At six weeks of age, the child developed convulsions and deteriorating neurologic status. CT scan showed subarachnoid haemorrhage. The child was referred for further workup. Additional assay of clotting factors showed decreased FX activity at less than 1% and he was diagnosed with severe congenital FX deficiency. Following recurrent intracranial bleeding, the child has been observed to have permanent neurological deficit. This case highlights the importance of timely and accurate diagnosis to prevent life-threatening complications and the risk of permanent disability. Despite being an extremely rare disorder, the incidence of FX deficiency is estimated to be higher in populations where consanguineous marriages are common. Awareness of this rare condition must be emphasised. Families may benefit from screening through coagulation studies as well as genetic counselling, especially when planning future pregnancies. The rarity of this condition has not allowed for the establishment of evidence-based management guidelines, with treatment based on limited literature. Despite development of FX-specific clotting factor products, the high cost and limited availability impact their use in low-resource settings.

Postoperative opioid-prescribing practices in otolaryngology: Evidence-based guideline outcomes.

We previously reported that >50% of postoperative opioids prescribed at our institution went unused for common otolaryngologic procedures. Based on these findings, we instituted multimodal, evidence-based guidelines for postoperative pain management. In the second part of our multiphasic study, we evaluated the effects of these guidelines on (1) quantity of unused opioids, (2) patient satisfaction, and (3) institutional perceptions toward the opioid epidemic and prescribing guidelines. Standardized, procedure-specific opioid prescription guidelines were created using prospective data from the first phase of our study and evidence from current literature. Again, we examined sialendoscopy, parotidectomy, parathyroidectomy/thyroidectomy, and transoral robotic surgery (TORS). Patients were surveyed at their first postoperative appointment. Groups from Phases I and II were compared. Attending physicians were surveyed before the start of the multiphasic project and after prescribing guidelines were implemented. Prescribing guidelines led to an average reduction in prescribed morphine milligram equivalents (MME) per patient by: 48% (sialendoscopy), 63% (parotidectomy), 60% (para/thyroidectomy), and 42% (TORS). Average used MME per patient for parotidectomy was significantly reduced (64%). The proportion of unused MME per patient and patient satisfaction scores did not significantly change after guidelines were implemented. Implementation of opioid-prescribing guidelines and the use of multimodal analgesia substantially reduced the amount of opioids prescribed across all procedures without impacting patient satisfaction. 2.

Substitute vs permanent teacher job satisfaction: applying MUSA to delineate differences and highlight evidence-based guidelines for decision makers

PurposeThe purpose of this paper is threefold. First, to explore the importance of specific work environment facets for the overall job satisfaction (JS) of primary full-time permanent teachers (PTs) and substitute/temporary teachers (STs). Second, to highlight the similarity or difference in JS patterns among PTs and STs. Third, to provide guidelines for effective evidence-based human resource management (HRM) interventions targeting to boost PTs and STs JS levels by considering: (1) the perceived importance of individual work facets for them and (2) the school's performance in providing a satisfactory work environment.Design/methodology/approachData on overall and important JS facets (i.e. satisfaction with opportunities for self-fulfillment, work intensity/load, salary/income, leadership and collegial relations) were collected from a sample of 438 PTs and STs in Greece. Moreover, MUSA, a method that combines Multi-Criteria Decision (MCDA) and Importance-Performance Analysis (IPA), was applied to uncover the critical work environment facets of PTs and STs overall JS that call for interventions.FindingsThe findings suggest that PTs seem to value, more than STs, the transactional and economic aspects of the school environment. More precisely, on the part of PTs, self-fulfillment and salary/income are the main contributors to their JS, whilst leadership is the least important facet of JS. For STs self-fulfillment and collegial relationships are the aspects of work that contribute the most to their overall JS, whilst salary/income is the least important contributor. The study results further indicate that self-fulfillment is the strong attribute of Greek schools' work environment in boosting TJS regardless teachers' status, whilst salary/income and workload are potential threats.Originality/valueIt is one of the few studies that provide insights into the differing JS patterns of STs and PTs through the application of a MCDA/IPA method. Therefore, it offers evidence-based guidelines that take into consideration both the school's performance (overall and facet JS) and importance of core aspects of the work experience for STs and PTs.

Applying a knowledge translation framework for triaging low back pain and radicular pain at an emergency department: an iterative process within an uncontrolled before-and-after design

BackgroundDiagnostic imaging for low back pain (LBP) without any indication of a serious underlying cause does not improve patient outcomes. However, there is still overuse of imaging, especially at emergency...

CO149 Epidemiology and Burden of Oral Complications Following Breast Cancer Treatment - A Systematic Literature Review (PROSPERO CRD42021272130) - Mucositis and Stomatitis Incidence From Randomized Trials

Breast cancer (BC), the most prevalent malignancy among women, has good survival rates given the numerous treatments available according to disease and patient characteristics. However, all pharmacological treatments are associated with several adverse effects (AE). Established evidence-based management guidelines are available for most AEs but not for oral complications (OC). Negative oral health is commonly reported during and after BC treatment and exerts a negative impact on quality of life, yet OCs are often overlooked or receive delayed interventions that are mostly performed empirically.

Abstract #1313472: Adherence of Physicians to Evidence-Based Management Guidelines for Treating Type 2 Diabetes and Atherosclerotic Cardiovascular Disease in Ajman, United Arab Emirates

Good adherence by physicians to treatment guidelines for T2DM could improve therapy outcome for patients. In this retrospective, cross-sectional study, we assessed physicians’ adherence to evidence-based guidelines for T2DM management in adult patients (aged ≥18 years) with either confirmed atherosclerotic cardiovascular disease (ASCVD) or those at high risk of developing ASCVD at the Thumbay Hospital Ajman an Academic Health Center affiliated with Gulf Medical University - United Arab Emirates

Assessing the impact of a national clinical guideline for the management of chronic pain on opioid prescribing rates: a controlled interrupted time series analysis

BackgroundOpioids can be effective analgesics, but long-term use may be associated with harms. In 2013, the first national, comprehensive, evidence-based pain management guideline was published, from the Scottish Intercollegiate Guideline Network (SIGN 136: Management of Chronic Pain) with key recommendations on analgesic prescribing. This study aimed to examine the potential impact on national opioid prescribing rates in Scotland.MethodsTrends in national and regional community opioid prescribing data for Scotland were analysed from quarter one (Q1) 2005 to Q2 2020. Interrupted time series regression examined the association of SIGN 136 publication with prescribing rates for opioid-containing drugs. Gabapentinoid prescribing was used as a comparison drug.ResultsAfter a positive prescribing trend pre-publication, the timing of SIGN 136 publication was associated with a negative change in the trend of opioid prescribing rates (−2.82 items per 1000 population per quarter [PTPPQ]; P < 0.01). By Q2 2020, the relative reduction in the opioid prescribing rate was −20.67% (95% CI: −23.61, −17.76). This persisted after correcting for gabapentinoid prescribing and was mainly driven by the reduction in weak opioids, whereas strong opioid prescribing rates continued to rise. Gabapentinoid prescribing showed a significant rise in level (8.00 items per 1000 population; P = 0.01) and trend (0.27 items PTPPQ; P = 0.01) following SIGN 136 publication.ConclusionsThe publication of SIGN 136 was associated with a reduction in opioid prescribing rates. This suggests that changes in clinical policy through evidence-based national clinical guidelines may affect community opioid prescribing, though this may be partially replaced by gabapentinoids, and other factors may also contribute.

Commercial Question Banks Present a Limited Scope of Sickle Cell Disease

INTRODUCTION Question banks are the most widely used educational resource for medical students and graduate medical trainees studying for professional licensing exams and are the preferred platform both for learning new material and for review. Trainees who use question banks to prepare for these critical exams achieve higher scores on their United States Medical Licensing (USMLE) Steps 1-3, which in turn predict success in residency clinical performance and ultimately, board certification. The content of question banks can therefore be regarded as a strong predictor of the clinical knowledge medical trainees are expected to master. This foundational knowledge base plays an important role in the formation and reinforcement of "illness scripts” that unconsciously drive real-life clinical decision-making. Sickle cell disease (SCD) is an underserved area of healthcare with large disparities between research-proven interventions and clinical practice. In particular, the growing population of adults with SCD suffer high morbidity and mortality due to insufficient access to SCD specialists and comprehensive SCD care. Most patients with SCD seek care from centers without important clinical expertise. Family physicians, internists, and ED physicians are primarily responsible for the treatment of many with SCD. When surveyed, these physicians report high levels of discomfort with SCD management due to lack of specialized knowledge and training. Our study is the first to examine SCD content in commercial question banks and determine how the disease is portrayed to medical trainees. We hypothesize that the pathophysiologic and clinical scope of SCD portrayed by question banks does not reflect the true epidemiology or scope of this complex disease. METHODS Nine of the most widely used commercial question banks for undergraduate and graduate medical trainees were accessed and searched for questions related to SCD. Inclusion criteria consisted of questions in which SCD was intended as the educational objective as featured in the question stem only. Questions were excluded if they featured SCD among the answer choices only, answer explanations only, or if sickle cell trait was intended as the primary educational objective. Questions that met all criteria were transcribed into RedCap software and three reviewers independently coded questions for content. Code book variables like sickle cell disease clinical complications were compiled using the 2014 NHLBI evidence-based guidelines for management of SCD. Questions coded with unique or discrepant entries were examined individually and final coding was determined by consensus. RESULTS A total of 22,152 questions were screened for inclusion from question banks listed in Table 1. Seventy unique questions featured SCD as the primary educational objective and were included in the analysis. Children aged 10 and younger formed the largest proportion of patients presented in questions (n=32, 45.7%). In contrast, data from the CDC Sickle Cell Data Collection Program shows healthcare utilization is lowest in children younger than 10 and increases with age [Green line in Figure 1]. The oldest patient in our dataset was 37 years old and there were two questions in which no patient age was mentioned. Clinical complications presented in questions were almost always acute (89%). The most common complications were acute pain, acute infection, and acute anemia presented in 42%, 41%, and 23% of questions, respectively. Only 4 patients (5.9%) presented in questions were taking hydroxyurea (HU). CONCLUSION Our novel study suggests that commercial question banks portray the patient with SCD as predominantly young and presenting with acute complaints. There is little focus on the multi-system organ dysfunction that ultimately drives the high morbidity and mortality associated with SCD. Disease-modifying treatments like hydroxyurea are rarely mentioned and evidence- based preventative care measures are not emphasized. Future research is needed to determine how this narrow portrayal of SCD risks reinforcing an overly simplistic "illness script” or narrative that may influence the clinical decision-making of practicing physicians. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Evidence-based practical guideline for procedural pain management and sedation for burn pediatrics patients undergoing wound care procedures.

Almost all children with burns experience pain as a result of a complex pathophysiologic process that is usually untreated, and up to 38% of all pediatric burn victims develop anxiety disorders due to pain after hospital admission. Hence, it is important to manage pain and anxiety in the care of burn victim children. The goal of this review was to develop an evidence-based guideline for procedural pain management and sedation for burned children undergoing wound care procedures. The review was reported according to Reporting Items for practice Guidelines in Healthcare (RIGHT) protocol. A search of literature was done from Cochrane review, PubMed, Google Scholar, Embase, web of science and Hinari database key words "pediatrics", "children", "burn", "procedural wound care", "wound dressing", "non-pharmacological", "analgesia", "pain management" and "sedation" were used. Extraction and filtering of the results was determined based on the interventions, outcome, population, and methodological quality, and inclusion and exclusion criteria. Finally, 6 systematic review and meta-analysis, 1observational study, and 16 randomized control trial Studies were appraised for quality, and conclusion was made based on their level of evidence and grade of recommendation. For effective management of procedural pain and accompanying anxiety during WCP in children, we recommend using non-pharmacological strategies as an adjunct with calculated dose of analgesics based on the children's analgesic requirements. We also recommend ketamine-dexmedetomidine as an effective first-line analgesic-sedation, and ketamine-propofol, propofol-remifentanil, propofol-fentanyl, and ketamine-midazolam as useful sedative-analgesic options.

Updates on Pharmacologic Management of Microvascular Angina.

Microvascular angina (MVA), historically called cardiac syndrome X, refers to angina with nonobstructive coronary artery disease. This female-predominant cardiovascular disorder adds considerable health-related costs due to repeated diagnostic angiography and frequent hospital admissions. Despite the high prevalence of this diagnosis in patients undergoing coronary angiography, it is still a therapeutic challenge for cardiologists. Unlike obstructive coronary artery disease, with multiple evidence-based therapies and management guidelines, little is known regarding the management of MVA. During the last decade, many therapeutic interventions have been suggested for the treatment of MVA. However, there is a lack of summarization tab and update of current knowledge about pharmacologic management of MVA, mostly due to unclear pathophysiology. In this article, we have reviewed the underlying mechanisms of MVA and the outcomes of various medications in patients with this disease. Contrary to vasospastic angina in which normal angiogram is observed as well, nitrates are not effective in the treatment of MVA. Beta-blockers and calcium channel blockers have the strongest evidence of improving the symptoms. Moreover, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, statins, estrogen, and novel antianginal drugs has had promising outcomes. Investigations are still ongoing for vitamin D, omega-3, incretins, and n-acetyl cysteine, which have resulted in beneficial initial outcomes. We believe that the employment of the available results and results of the future large-scale trials into cardiac care guidelines would help reduce the global cost of cardiac care tremendously.

Implementing the evidence: Routine screening for depression and anxiety in primary care

Background: Primary care providers are qualified to treat, diagnose, and manage common mental health issues like anxiety and depression. Anxiety and depression are common among college age students, with the average age of onset occurring in one’s late teens to early 20s. Screening tools are commonly used to recognize patients who may be at risk for anxiety and depression. Purpose: The purpose of this evidence-based practice project was to (a) implement evidence-based guidelines for screening and management of college-aged patients with anxiety and/or depression and (b) to develop an algorithm that describes evidence-based management to guide providers at two student health centers. Methods: All patients who registered for a sick visit or other appointment at the project site were screened for anxiety and depression using two validated tools. An algorithm to help healthcare providers properly assess and better treat anxiety and depression was developed and implemented for this project. Results: A total of 366 patients were screened for depression and anxiety over a 3-month period. Using the created algorithm, patients received education on anxiety and/or depression and a counseling referral. If warranted, patients were prescribed medication therapy for depression and/or anxiety. Conclusion: Screening for anxiety and depression has become the standard of care in primary care clinics. Routine screening tools help healthcare providers identify patients with anxiety and depression. Early identification and diagnosis of anxiety and depression leads to better outcomes in treatment.

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].

Emergency colectomies in the NOAC era: a nationwide analysis demonstrating increased complications.

The use of Non-vitamin K antagonist oral anticoagulants (NOAC) has increased substantially since their introduction in 2010. The lack of readily available reversal agents poses a challenge in perioperative management. The aim of this study was to evaluate the impact of NOACs on the outcomes of emergency colectomies. All adult patients on long-term anticoagulation who underwent emergency colectomies were identified from the Nationwide Inpatient Sample (NIS) database from 2002 to 2018. Long-term anticoagulation was defined using ICD-9/10 codes. Two cohorts were compared: anticoagulated patients in the pre-NOAC era (2002-2010) and anticoagulated patients in the NOAC era (2010-2018). Outcomes of interest were postoperative surgical complications, mortality and need for transfusion. Of 13,218 patients on long-term anticoagulation, 3,264 patients were treated in the pre-NOAC era and 9,954 in the NOAC era. Over the study period, there was a significant increase in the proportion of anticoagulated patients undergoing emergency colectomies (R2 = 0.91). On univariate analysis, anticoagulated patients in the NOAC era were medically more comorbid and had higher rates of postoperative surgical complications (73.3% vs 60.3%, p < 0.001) and mortality (8.2% vs. 6.7%, p = 0.006), but had lower rates of postoperative bleeding (3.5% vs. 4.4%, p = 0.002) and transfusions (38.1% vs. 45.4%, p < 0.001). On multivariable regression, after accounting for clinically significant covariates, anticoagulation in the NOAC era was associated with decreased rates of postoperative bleeding (OR 0.70, 95%CI 0.57-0.88) and transfusions (OR 0.71 95%CI 0.64-0.77) but remained an independent predictor of increased overall postoperative complications (OR 1.26, 95%CI 1.14-1.39). Prevalence of long-term anticoagulation in patients undergoing emergency colectomies is increasing. Although associated with lower rates of postoperative bleeding and transfusions, anticoagulation in the NOAC era is associated with higher rates of overall postoperative complications. Evidence-based guidelines for perioperative management of patients on NOACs in the emergency colorectal surgery setting are needed.