Practice Guidelines Research Articles

Diets to promote healthy brain ageing.

Diet is a modifiable lifestyle factor with a proven role in cardiovascular disease risk reduction that might also play an important part in cognitive health. Evidence from observational studies has linked certain healthy dietary patterns to cognitive benefits. However, clinical trials of diet interventions have demonstrated either null or, at best, small effects on cognitive outcomes. In this Review, we summarize the currently available evidence from observational epidemiology and clinical trials regarding the potential role of diet in theprevention of cognitive decline and dementia. We further discuss possible methodological limitations that might have hindered the ability of previous diet intervention trials to capture potential neuroprotective effects. Considering the overwhelming and continuously expanding societal, economic and health-care burden of Alzheimer disease and other dementias, future nutritional research must address past methodological challenges to accurately and reliably inform clinical practice guidelines and public health policies. Within this scope, we provide a roadmap for future diet intervention trials for dementia prevention. We discuss study designs involving both intensive personalized interventions - to evaluate pharmacokinetic and pharmacodynamic properties, establish neuroprotective thresholds, and test hypothesized biological mechanisms and effects on brain health and cognition through sensitive and precise biomarker measures - and large-scale, pragmatic public health interventions to study population-level benefits.

Clinical benefits of adding olanzapine to 5-HT3 receptor antagonist, NK1 receptor antagonist, and dexamethasone for the prevention of nausea and vomiting in highly emetogenic chemotherapy: a systematic review and meta-analysis of the Clinical Practice Guidelines for Antiemesis 2023 from the Japan Society of Clinical Oncology.

Olanzapine is an atypical antipsychotic drug used for chemotherapy-induced nausea and vomiting. It is particularly effective in preventing delayed nausea and vomiting induced by highly emetogenic chemotherapy (HEC). However, it has side effects, such as hyperglycemia and somnolence, the efficacy and safety of adding olanzapine to triplet antiemetic therapy (5-HT3 receptor antagonist, NK1 receptor antagonist, and dexamethasone) must be verified. We performed a systematic review and meta-analysis to compare the effectiveness of olanzapine combined with triplet antiemetic therapy and triplet antiemetic therapy in preventing nausea and vomiting for HEC. We set five items (hyperglycemia, prevention of vomiting, prevention of nausea, adverse events, and cost (drug costs)) as outcomes and conducted a systematic review. Five randomized controlled trials was extracted and they showed that the addition of olanzapine was effective in control of nausea and vomiting, especially in the delayed phase. Complete response of acute and delayed phase were significantly higher in the olanzapine group. Risk difference was - 0.14 [95% CI - 0.26, - 0.03; p = 0.02] and - 0.14 [95% CI - 0.19, -0.09; p < 0.00001], respectively. Additionally, we evaluated hyperglycemia and somnolence, which are typical side effects of olanzapine. However, the incidence of grade ≥ 2 was low in both events, and there was no significant difference between olanzapine and control groups. Adding olanzapine to triplet antiemetic therapy is useful in preventing nausea and vomiting induced by HEC and there would be minimal adverse effects from the combination use.

Challenges in the Implementation of EU Risk Minimisation Measures for Medicinal Products in Clinical Practice Guidelines: Mixed Methods Multi-Case Study.

Risk minimisation measures (RMMs) aim to ensure safe use of medicines, but their implementation in clinical practice is complicated by the diversity of stakeholders whose clinical decision making they seek to inform. Clinical practice guidelines (CPGs) are considered integral in clinical decision making. To determine the extent to which RMMs are included in the relevant CPGs and to describe factors that determine RMM inclusion. A multi-case study design using quantitative document analysis of CPGs combined with qualitative interviews with informants from organisations that issue CPGs. Cases from five therapeutic areas (TAs) with a regulatory requirement for further RMMs were studied individually in six EU member states (Denmark, Greece, Latvia, Netherlands, Portugal and Slovenia). Clinical practice guidelines were analysed using pre-defined coding frameworks. Interviewees were sampled purposively for experience and knowledge about CPG development and RMM inclusion. Verbatim interview transcripts were analysed inductively. In total, 136 CPGs were analysed, and RMM information about TAs was included in 25% of CPGs. Based on 71 interviews we found that factors that determine RMM inclusion in CPGs include clinicians' low awareness of RMMs despite awareness of RMMs' safety concern, low expectation of RMMs' clinical utility, and unfamiliarity with pharmacovigilance data supporting RMMs and perceived incompatibility of CPGs' scope and purpose and RMM information. The inclusion of RMM information in relevant CPGs is remarkably limited. It may be explained by characteristics of CPGs and of RMMs as well as lack of connection between national regulators and organisations and authors developing CPGs. More collaboration between stakeholders, national regulators and the EMA may advance implementation.

Evaluation and Treatment of Acute Facial Palsy: Opportunities for Optimization at a Single Institution.

Introduction: Most patients with acute facial palsy initially present to emergency departments (EDs), where clinical practice guidelines (CPGs) recommend steroids, eye care, and follow-up with facial nerve specialists. Objective: To evaluate adherence to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Bell's palsy (BP) CPGs within EDs at a single academic institution. Method: We conducted a retrospective review of all patients diagnosed with acute facial palsy in the EDs of an academic tertiary care center between June 1, 2021, and June 1, 2022. Results: A total of 270 patients met inclusion criteria; most were male (n = 150, 55.9%), diagnosed with BP (n = 243, 90.0%), and presented to community-based emergency rooms (n = 170, 62.96). Although most patients received steroid treatment (n = 243, 90.0%), only 61.5% (n = 166) received the AAO-HNS-recommended course. Older patients and those who received steroids were more likely to receive imaging (p < 0.001, p = 0.03). Treatment with the AAO-HNS-recommended steroid regimen was associated with a higher likelihood of receiving laboratory evaluation (p = 0.02). Providers often advised follow-up; however, only 12.2% of patients were discharged with an electronic referral order. Conclusion: There are opportunities to standardize the treatment of patients in the ED presenting with acute facial palsy according to AAO-HNS CPGs.

The Quality of Evidence Supporting Clinical Practice Guidelines in General Surgery

This meta-analysis assesses the strength and quality of clinical recommendations in practice guidelines published by professional societies.

Risk Factors for Preeclampsia: Received Wisdom Versus Reality

(BJOG. 2024;131(1):63. doi: 10.1111/1471-0528.17311) Prevention of many pregnancy-related complications can be better accomplished when risk factors (RF) for these conditions are considered. An example of this is preeclampsia (PEC), where the preventative measures of aspirin and calcium have been shown to reduce the incidence of the condition. Preventive strategies for PEC are determined heavily by clinical practice guidelines (CPGs), which rely on screening for RFs.

Integrating Endocrine, Genomic, and Extra-Skeletal Benefits of Vitamin D into National and Regional Clinical Guidelines.

Vitamin D is essential for bone health, immune function, and overall well-being. Numerous ecological, observational, and prospective studies, including randomized controlled clinical trials (RCTs), report an inverse association between higher serum 25-hydroxyvitamin D [25(OH)D; calcifediol] levels in various conditions, including cardiovascular disease, metabolic disorders such as diabetes and obesity, susceptibility to infection-related complications, autoimmune diseases, and all-cause mortality. Vitamin D operates through two distinct systems. The endocrine system comprises the renal tubular cell-derived circulatory calcitriol, which primarily regulates calcium homeostasis and muscular functions. In contrast, intracellularly generated calcitriol in peripheral target cells is responsible for intracrine/paracrine system signaling and calcitriol-vitamin D receptor-mediated genomic effects. Government-appointed committees and health organizations have developed various clinical practice guidelines for vitamin D supplementation and management. However, these guidelines heavily relied on the 2011 Institute of Medicine (IoM) report, which focused solely on the skeletal effects of vitamin D, ignoring other body systems. Thus, they do not represent maintaining good overall health and aspects of disease prevention. Additionally, the IoM report was intended as a public health recommendation for the government and is not a clinical guideline. New country- and regional-specific guidelines must focus on healthy nations through disease prevention and reducing healthcare costs. They should not be restricted to bone effect and must encompass all extra-skeletal benefits. Nevertheless, due to misunderstandings, medical societies and other governments have used faulty IoM report as a foundation for creating vitamin D guidelines. Consequently, they placed disproportionate emphasis on bone health while largely overlooking its benefits for other bodily systems, making current guidelines, including 2024, the Endocrine Society less applicable to the public. As a result, the utility of published guidelines has been significantly reduced for clinical practice and RCTs that designed on bone-centric are generate misleading information and remain suboptimal for public health and disease prevention. This review and its recommendations address the gaps in current vitamin D clinical practice guidelines and propose a framework for developing more effective, country and region-specific recommendations that capture the extra-skeletal benefits of vitamin D to prevent multiple diseases and enhance public health.

Risk Factors for Preeclampsia in Clinical Practice Guidelines: Comparison With the Evidence

(BJOG. 2024;131:46–62. DOI: 10.1111/1471-0528.17320) Preeclampsia affects 2% to 4% of pregnancies globally, with a rising incidence linked to increasing maternal age and body mass. This hypertensive disorder poses significant risks to both maternal and fetal health, making it a key focus of prenatal care through blood pressure and proteinuria screening. Despite the lack of an approved treatment to modify the disease, current best practices involve identifying at-risk women, administering preventative therapy, managing hypertension, and other organ impacts if preeclampsia develops, and ultimately, timing the birth to resolve the condition.

Cardiovascular and renal benefits of sodium-glucose cotransporter-2 inhibitors: pathophysiologic mechanisms and clinical evidence.

Large-scale clinical outcome trials have demonstrated significant reductions in cardiovascular (CV) and renal outcomes with sodium-glucose cotransporter-2 inhibitors (SGLT2i). These benefits are sustained in patients with a range of left ventricular ejection fractions (LVEF), irrespective of diabetes status, and in a variety of clinical settings, prompting incorporation into clinical practice guidelines for patients with chronic kidney disease (CKD), heart failure (HF), and atherosclerotic cardiovascular disease (ASCVD). The clinical benefits are mediated by an interplay of cardio-metabolic-renal mechanisms, and they have a favorable safety profile. We provide a review of the proposed mechanisms of cardiorenal protection and the evidence supporting the clinical benefits of SGLT2i in CKD, acute and chronic HF treatment and prevention , and ASCVD, highlighting the uses of SGLT2i in clinical practice guidelines.

Transatlantic Delphi Consensus on the Common Iliac Artery Sealing Zone in Endovascular Aorto-Iliac Aneurysm Repair (the DECIDE Study).

Knowledge of hostile factors and their influence on long-term seal in the iliac landing zone is limited. Currently endorsed clinical practice guidelines lack structural evidence on how the iliac landing zone should be assessed in the pre-, intra-, and postoperative phases. The goal of this study was to obtain an international, expert-based consensus on the definition of a hostile iliac landing zone, on how to size and plan stent-grafts to optimize sustainable distal seal, and on the postprocedural follow-up protocol. Delphi consensus methodology was used, involving a panel of international vascular surgeons experienced in endovascular aneurysm repair (EVAR). The first round consisted of open-ended and multiple-choice questions to explore current practices, with subsequent rounds refining statements through a 4-point Likert scale. Consensus was defined as >75% agreement or disagreement, and the analysis included stability testing and strength of consensus. The study engaged 77 international vascular surgeons, reflecting diverse geographic locations and hospital affiliations. Consensus was achieved on critical preoperative planning elements for EVAR, including a clear definition for a hostile iliac landing zone. The importance of computed tomography angiography for postoperative follow-up imaging was emphasized, including evaluating distal seal length and recommending specific timing for follow-up computed tomography scans and intervention strategies for diminishing iliac seal. This international expert-based Delphi consensus establishes a comprehensive set of consensus-driven recommendations focused on the definition and management of hostile iliac landing zones in EVAR. The key recommendation of this study is the definition of a hostile iliac landing zone as short (<15 mm), wide (>24 mm), or conical (>10% diameter difference along the landing zone). Although consensus was achieved on several critical aspects, the study also reveals ongoing debates and considerations that warrant further exploration, including how to tackle diminishing seal without a type IB endoleak. This Delphi consensus introduces a standardized definition of a hostile iliac landing zone as short (<15 mm), wide (>24 mm), or conical (>10% diameter difference), clinicians now have a clearer framework for assessing complex anatomies. This study provides a comprehensive set of consensus-driven recommendations focused on the definition and management of hostile iliac landing zones in EVAR which gives guidance where current guidelines lack specificity, particularly for distal iliac sealing. The study also reveals ongoing debates and considerations that warrant further exploration, including how to tackle diminishing seal without a type IB endoleak.

Low-value and high-value care recommendations in nursing: Asystematic assessment of clinical practice guidelines.

The World Health Organization defines quality of care as providing effective, evidence-based care, and avoiding harm. Low-value care provides little or no benefit to the patient, causes harm, and wastes limited resources. In 2017, shortly after the start of the International Choosing Wisely campaign, the first Dutch nursing "Do-not-do" list was published and has become a widely used practical tool for nurses working in daily practice. However, over the last years new guidelines are published. Therefore, an update of the list is necessary with an addition of high-value care recommendations as alternative care practices for low-value care. In this study, a combination of designs was used. First, we searched Dutch clinical practice guidelines for low-value or high-value care recommendations. All nursing care recommendations were assessed and specified to several healthcare sectors, including hospital care, district care, nursing home care, disability care, and mental health care. Second, a prioritization among nurses regarding low-value care recommendations was done by a cross-sectional survey for each healthcare sector. In total, 66 low-value care recommendations were found, for example, "avoid unnecessary layers under the patient at risk of pressure ulcers" and "never flush the bladder to prevent urinary tract infection." Furthermore, 414 high-value care recommendations were selected, such as "use the Barthel Index to assess and to evaluate the degree of ADL independence" and "application of cold therapy may be considered for oncological patients with pain." In total, 539 nurses from all healthcare sectors prioritized the low-value care recommendations, resulting in a top five low-value care practices per healthcare sector. The top five low-value care recommendations differed per healthcare sector, although "do not use physical restraints in case of a delirium" was prioritized by four out of five sectors. Assessing low-value and high-value care recommendations for nurses will help and inspire nurses to deliver fundamental care for their patients. These initiatives regarding low-value and high-value care are essential to generate a culture of continuous quality improvement based on evidence. This is also essential to meeting the current challenges of the healthcare delivery system. This paper provides an update of low-value care recommendations for nurses based on Dutch guidelines from 2017 to 2023, specified to five healthcare sectors, including hospital care, district care, nursing home care, disability care and mental health care, with an accompanying prioritization of these low-value care recommendations to facilitate de-implementation. This paper provides a first overview of high-value care recommendations to reflect on and create alternative care practices for low-value care. The recommendations regarding low-value and high-value care are essential to generate a culture of continuous improvement of appropriateness based on evidence, finally leading to better quality of care and improving patient outcomes.

Trends in Overactive Bladder Therapy: Associations Between Clinical Care Pathways, Practice Guidelines, and Therapy Utilization Patterns.

Overactive bladder (OAB) is a chronic condition with significant financial and health-related consequences. Guidelines and treatment pathways were created to optimize care and provide a clinical framework for diagnosing and managing OAB. However, the impact of these efforts and patterns of medical treatment for OAB are poorly understood. Therefore, we sought to evaluate overall trends in therapy utilization before and after the 2014 American Urological Association (AUA)/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) OAB guideline amendment and publication of the OAB clinical care pathway in 2016. In this retrospective cohort study, we analyzed data from Optum, a national administrative health and pharmacy claims database, between 2013 and 2018. All adult patients diagnosed with idiopathic OAB were identified by the International Classification of Diseases 9th and 10th Revision codes. Oral OAB therapies were identified using National Drug Codes, while third-line therapy procedures, onabotulinumtoxinA (BTX), sacral neuromodulation (SNM), and percutaneous tibial nerve stimulation (PTNS), were identified using Current Procedural Terminology (CPT) codes. The study's primary outcome was the annual number of OAB prescriptions filled by pharmacotherapy class and the number of minimally invasive therapies performed during the study period. The secondary outcome was the association between OAB therapy utilization and various clinical and sociodemographic factors. Patterns of care were analyzed from 2013 to 2018, and initial treatment with each therapy was collected, excluding repeat procedures from the analysis. 1 825 782 patients were included in the study. The mean age was 61.1 ± 16.7 years, and 1 071 420 patients were female (58.7%). The number of new OAB diagnoses increased by 369% from 2013 to 2017. During the 6-year study period, 347 052 (19%) patients were treated with oral and/or third-line therapies. The overall number of oral medications prescribed peaked in 2016, followed by a 17% decline between 2016 and 2018. In 2013, the two most prescribed oral medications were oxybutynin (46%) and solifenacin (31.8%). By 2018, mirabegron (18.5%) surpassed solifenacin (16.5%), with oxybutynin still accounting for most prescriptions written (55%). Eighty percent of all initial mirabegron prescriptions were filled by patients over the age of 65. The rate of third-line therapy procedures almost doubled between 2013 and 2018 (9-17 procedures per 1000 OAB patients, p < 0.001). Following the publication of the first OAB guidelines, there was an increase in OAB diagnoses, followed by a decrease in anticholinergic medication use, and a rise in beta-3 agonist utilization in patients over 65 years old. Additionally, there was greater adoption of third-line OAB therapies. These trends indicate that OAB therapy guidelines and clinical practice pathways may influence treatment patterns. Given the recent publication of the OAB guidelines, further studies are necessary to assess their impact on therapy utilization patterns.

Implementation and Evaluation of Cultural Safety Initiatives in Australian Hospital Settings: A Scoping Review.

The aim of this scoping review was to synthesize and summarize existing evidence for implementing and evaluating Cultural Safety initiatives in Australian hospitals for Aboriginal and Torres Strait Islander peoples. The rationale for this work was to establish guidelines for best practice in providing culturally safe care across hospital and health services. A systematic search guided by PRISMA Extension for Scoping Reviews was conducted across five databases: CINAHL, Scopus, MEDLINE, Embase, and Informit. Reference lists and citations of eligible studies were also examined. Studies were eligible for inclusion if they were in English and discussed the implementation and/or evaluation of Cultural Safety initiatives in Australian hospitals. Evaluations assessing both health care staff and patient perspectives were included. Studies were excluded if they presented future implementation protocols or initiatives among health care students. No date limiters were applied due to the small body of available literature. Nine studies met the criteria and were included in this review. Five themes emerged: (a) process of implementation; (b) process of evaluation; (c) change in health professional's behavior; (d) change in patient behavior; and (e) future recommendations. Validated implementation frameworks and evaluation tools are needed for integrating Cultural Safety initiatives into Australian hospital settings. This review has highlighted that despite the availability of evidence-based tools, their use was lacking. This scoping review also highlighted that evaluation of Cultural Safety initiatives is primarily focused on the attitudes and knowledge of health professionals, rather than patient experience. As Cultural Safety is determined by recipients of care, future evaluation of initiatives should prioritize patient perspectives.

ERNICA Evidence Based Guideline on Surgical Aspects of Necrotizing Enterocolitis in Premature Neonates

Background Necrotizing enterocolitis (NEC) is a severe intestinal condition primarily affecting preterm neonates. It has ahigh mortality rate, particularly in infants with a birth weight of below 1500 grams or for those requiring surgical intervention. The European Reference Network for Inherited and Congenital Anomalies (ERNICA) has developed a clinical practice guideline to aid clinical decision-making pertaining to the surgical treatment and management of NEC in preterm neonates. Summary This guideline was developed in accordance with the Guidelines 2.0 checklist and GRADE methodology. A multidisciplinary group of Europe’s top experts collaborated with patient representatives to develop this guideline. After selecting critical points in care for which recommendations are required, a systematic review of the literature and critical appraisal of the evidence was performed. The Evidence to Decision framework was used as a guide to structure the consensus meetings and draft the recommendations. The panel developed seven recommendations and three good-practice statements on the following topics: indications for surgery, peritoneal drainage, surgical technique, management of extensive NEC, enteral feeding and neurodevelopmental outcomes in premature neonates with NEC. The certainty of evidence was graded as (very) low for most recommendations. However, the panel weighed up the benefits and harms in light of all relevant arguments and expert opinion. Key Messages This guideline provides recommendations on caring for premature neonates with NEC. These recommendations can assist clinicians in their care decisions and can inform families on treatment options and relevant considerations. This guideline will be revised every five years to ensure it remains up to date.

Correction to: 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Correction to: 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Window Coverage and Liquid Biopsy in the First-Line Therapy of Severe Sudden Sensorineural Hearing Loss.

Based on clinical practice guidelines, the application of corticosteroids as a first-line therapy is common. Although sudden sensorineural hearing loss (SSHL) etiology is primarily idiopathic, hearing loss can result from a perilymphatic fistula (PLF). Recent findings show evidence of a specific rate of PLF based on a cochlin-tomoprotein (CTP) detection test. Based on this rate of PLF treatment, the concepts of SSNHL need to be re-evaluated. The present study aimed to evaluate CTP in SSNHL patients and compare pre-surgical and post-surgical pure tone hearing thresholds after round and oval window sealing as first-line treatment. A total of 30 patients with unilateral SSNHL with a pure tone average (PTA) (4 Freq. of 60 dB or more were enrolled in a prospective study. All patients underwent tympanoscopy for middle ear exploration as a first-line treatment. After intraoperative observation of a possible PLF, all patients obtained middle ear lavage to gain CTP samples for following ELISA-based CTP detection tests. All patients received round window and oval window sealing with fascia. PTA hearing thresholds were analyzed post-surgically 3 weeks after treatment based on 4-frequency bone conduction (BC). The average preoperative pure tone BC threshold was 97.7 dB compared with the 69 dB postoperative BC threshold. Mean BC improved by 20.3 dB after middle ear exploration and window sealing. A total of 56% (17 of 30) of patients recovered at least 10 dB. The middle ear cochlin-tomoprotein detection rate was 70% positive. The combination of early tympanoscopy and inner ear-specific cochlin-tomoprotein as a detection tool for suspected PLF showed evidence of PLF as a key causative in SSNHL.

Examining How Structural Conditions, Cultural Norms, and Institutional Practices Shape Diagnostic Delays for Women in Ontario: A Critical Qualitative Study

There are a number of diseases and conditions that have notoriously long diagnostic periods. Often associated with a downplaying or dismissal of symptoms and feelings of shame, many of these diseases and conditions disproportionately manifest among women. Endometriosis, for instance, takes on average three to ten years to diagnose, and cardiovascular disease, ADHD, and pain conditions such as fibromyalgia and rheumatoid arthritis represent other common examples. During a diagnostic delay – when the period becomes prolonged between seeking care until the point at which a diagnosis is made – women continue to suffer from symptoms, lose confidence in healthcare providers and systems, and experience interruptions to their lives, relationships, and sense of self. While several investigations have produced descriptive accounts of these reasons, they leave unaddressed women’s embodied experiences of diagnostic delays, socio-political structures and power relations, such as gender, and the interrelationships between these two components. To address this gap, I will draw on critical phenomenology to ask: How are diagnostic delays lived as embodied social practices by women?; What do narratives of diagnostic delay reveal about gendered embodiment during illness? and In what ways do women’s embodied experiences of illness resist, reinforce, and revise the cultural expectations and institutional practices that contribute to diagnostic delays?. In doing so, my research aims to understand how socio-political structures and power relations are intertwined with embodied experiences of diagnostic delay, and the ways the relationship between them serves to support and/or disrupt this phenomenon. Critical phenomenology engages with a wide range of critical disciplines to understand rich subjective experiences and how normalizing structures privilege some experiences and marginalize others. Drawing on this methodology, I will interview women with lived experience of diagnostic delay and clinicians who have experienced delays in diagnosing women. I will also review relevant practice guidelines and organizational policies to further contextualize this phenomenon. By exploring the intertwined nature of women’s embodied experiences of illness with social structures, and how these relationships serve to impact diagnostic delays for women, this project will importantly address the lack of specific and critical discourse on this phenomenon. In doing so, it will not only advance scholarship in this area, but will also support the continued discussion and advocacy that is essential to effecting change to this enduring and wicked problem.

Provider Identified Access Barriers to Delivering Acupuncture to Persons with Traumatic Brain Injury and Chronic Pain: A Cross-Sectional Self-Report Survey.

Objective: Traumatic brain injury (TBI) clinical practice guidelines for pain management and rehabilitation support the use of nonpharmacologic complementary and integrative health (CIH) modalities, such as acupuncture for remediating pain. Barriers to delivering CIH modalities, such as acupuncture warrant examination. The objective of this study is to explore provider perspectives on challenges to accessing acupuncture treatment for chronic pain in persons with TBI and describe differences across health care settings. Setting: Civilian, Veterans Affairs (VA), and Department of Defense health care systems. Participants: Health care providers (n = 145) were recruited from November 2022 to March 2023 via email through professional organizations and health care systems. Design: Descriptive cross-sectional self-report online survey. Main Measures: A survey assessed barriers using a 5-point Likert scale (always a barrier to never a barrier) using the Levesque Access to Care framework. Results: Of the 137 participants who provided information on setting, 86 (63%) worked in civilian health care; 47 (34%) worked in the Department of VA; and 4 (2.6%) in the Department of Defense (8 were missing data). Overall, providers endorsed all ten items as being barriers to accessing acupuncture treatment. However, these barriers were more statistically more frequently reported for civilian providers compared with VA providers for six of the 10 items, including lack of caregiver support (p < 0.0001); own knowledge and understanding of the treatment (p = 0.0025); health care setting culture discourages the treatment (p = 0.0181); lack of qualified providers (p = 0.0467); insurance does not cover (p < 0.0001), and patient cannot afford (p < 0.0001). VA provider respondents were more likely to answer all six items, as "Rarely/Never a Barrier," while providers in a civilian setting were more likely to respond "Always/Frequently" or "Sometimes" a barrier. Conclusion: Results reflect the cultural, organizational, and structural differences that make acupuncture more accessible within the VA. understanding barriers to delivering care is critical to inform implementation strategy mapping efforts, to tailor strategies that are aimed to increase access and engagement with acupuncture treatment in civilian health care settings.

HBV Biomarkers and Their Role in Guiding Treatment Decisions.

Over 300 million individuals worldwide are chronically infected with hepatitis B virus and at risk for progressive liver disease. Due to the lack of a therapy that reliably achieves viral elimination and the variability of liver disease progression, treatment decisions are guided by the degree of liver disease and viral biomarkers as the viral life-cycle is well characterized and largely conserved between individuals. In contrast, the immunological landscape is much more heterogeneous and diverse and the measurement of its components is less well standardized. Due to the lack of a universal and easily measurable set of biomarkers, clinical practice guidelines remain controversial, aiming for a balance between simplifying treatment decisions by reducing biomarker requirements and using all available biomarkers to avoid overtreatment of patients with low risk for disease progression. While approved therapies such as nucleos(t)ide analogs improve patient outcomes, the inability to achieve a complete cure highlights the need for novel therapies. Since no treatment candidate has demonstrated universal efficacy, biomarkers will remain important for treatment stratification. Here, we summarize the current knowledge on virological and immunological biomarkers with a specific focus on how they might be beneficial in guiding treatment decisions in chronic hepatitis B.

Management of patients at risk of harms from both continuing and discontinuing their long‐term opioid therapy: A qualitative study to inform the gap in clinical practice guidelines

AbstractBackgroundAlthough long‐term opioid therapy (LTOT) for chronic pain has declined, it remains common in the U.S. Providers do not have clinical practice guidelines for vulnerable LTOT patients, in whom both LTOT continuation and tapering to discontinuation pose risks of harm and in whom opioid use disorder (OUD) is absent.MethodsTo begin to meet the gap in guidelines, the study used a multiple case study approach. Five cases were constructed to systematically vary key elements of LTOT continuation and discontinuation harms among patients reporting LTOT's lack of efficacy (experience of pain and poor function). For each, treatment approaches were collected from 28 opioid safety experts identified through their participation in a national policy panel (19 were physicians) and analyzed using template analysis.ResultsFor patients receiving LTOT with harms of continuation and discontinuation, experts recommended attempting a slow taper (even with a prior unsuccessful taper, possibly with adjuvant medications to manage withdrawal) and not maintaining opioid therapy. Experts considered switching to buprenorphine, especially if the patient had aberrant behaviors. They also considered adding non‐opioid pain therapies (especially re‐trying such therapies if they were unhelpful before) and engaging in shared decisionmaking, although with little consensus on specific approaches. Some experts would address co‐occurring conditions related to patient safety (alcohol use, mental health symptoms, opioid side effects). Few experts referenced assessing or addressing OUD or overdose risk. In quantitative data, 36% of experts agreed LTOT is beneficial, 36% agreed most LTOT patients should be discontinued, and 57% agreed patients experience harm from tapering and from discontinuation.DiscussionEvidence is needed to build on and test these experts' recommendations to attempt tapering and add non‐opioid pain therapies for patients reporting harms of continued LTOT who may experience harms from tapering. Such evidence informs the development of clinical practice guidelines that provide comprehensive protocols to support the safety and functioning of this group of patients.