International Clinical Guidelines Research Articles

Cardiovascular Care of Turner Syndrome Women in Germany: Where Do We Stand?—Results from an Online Patient Survey

Background: This study aimed to investigate whether the cardiovascular care of Turner Syndrome (TS) women in Germany is in accordance with the latest clinical practice guidelines established by the 2016 Cincinnati international TS meeting. Methods: An anonymous online questionnaire was created to ask TS subjects about existing cardiovascular conditions and cardiovascular care received. Depending on cardiovascular morbidity and type of medical care received, the fulfillment of the latest clinical practice guidelines for the care of TS women was assessed. Results: 120 TS patients were included in this study. The mean age of TS subjects was 36.79 years. Only 80% of subjects received annual blood pressure measurements within the TS cohort, and only 60% received cardiac imaging according to international clinical practice guidelines. More than 55% of TS women did not feel well informed about TS-specific cardiovascular risk factors by their treating physician. Conclusions: A potential lack of cardiovascular care might be present in TS women in Germany as the results of this online patient survey suggest. The cardiovascular care of TS patients, particularly cardiac imaging and patient education, needs to receive more attention.

Systematic overview of systematic reviews and clinical guidelines: assessment and prevention of behavioural risk factors associated with oral cancer to inform dental professionals in primary care dental practices.

Aims/objectives Tobacco and alcohol are recognised as the major modifiable risk factors for oral cancer, the incidence of which is rising globally and predicted to increase. This paper aimed to: 1) appraise and synthesise best practice evidence for assessing the major behavioural risk factors for oral cancer and delivering behaviour change interventions (for example, advice, counselling, signposting/referral to preventive services); and 2) assess appropriateness for implementation by dental professionals in primary care.Methods A systematic overview was undertaken of systematic reviews and international clinical guidelines. This involved: systematically searching and collating the international literature on assessing oral cancer risk and delivering preventive interventions within primary care; quality appraising and assessing the risk of bias using validated tools; synthesising the evidence for best practice; and assessing application of key findings to the dental setting.Results and conclusions There is clear evidence for the effectiveness of a 'brief', in-person, motivational intervention for sustained tobacco abstinence or reduced alcohol consumption, following risk factor assessment. Evidence for combined behavioural interventions is lacking. There is no firm conclusion with regards to optimal duration of brief interventions (range 5-20 minutes). For tobacco users, longer (10-20 minutes) and intensive (more than 20 minutes, with follow-up visits) interventions are more effective in increasing quit rates compared to no intervention; very brief (less than five minutes) interventions in a single session show comparable effectiveness to the longer/more intensive interventions. For alcohol users, 10-15-minute multi-contact interventions were most effective, compared to no intervention or very brief (less than five minutes) intervention or intensive intervention; brief interventions of five-minute duration were equally effective. There is limited direct evidence from the dental practice setting (one high-quality systematic review relating to tobacco prevention and none relating to alcohol). Thus, very brief, or brief advice of up to five minutes, should be trialled for tobacco and alcohol respectively in a dental practice setting, after risk assessment tailored to patient motivational status. Exploring delivery by the dental team is supported, as effectiveness was generally independent of primary care provider.

Clinical interpretation and implementation of the sFlt-1/PlGF ratio in the prediction, diagnosis and management of preeclampsia.

Preeclampsia is associated with significant morbidity and mortality for mother and baby. Although around 30% of all pregnancies are evaluated for preeclampsia, diagnosis is difficult, especially in patients who have overlying symptoms from other diseases. Discovery of circulating angiogenic factors in the pathogenesis of preeclampsia has been a major advance for both diagnosis and prognosis. The anti-angiogenic factor, soluble fms-like tyrosine kinase 1 (sFlt-1) and the pro-angiogenic factor, placental growth factor (PlGF), can be measured in plasma and serum and are usually reported as a ratio, which specifically relates to the onset and severity of preeclampsia. The sFlt-1/PlGF ratio has a very high negative predictive value in ruling out the development of preeclampsia within 7days among women with suspected preeclampsia. Currently, there is no clear consensus on the practical use of angiogenic biomarkers in the detection and management of preeclampsia in routine clinical practice. While major international clinical guidelines exist, they do not define which specific parameters signal patient admission, or outpatient evaluation of suspected preeclampsia, and most clinicians follow local practices. Better guidance is needed on risk stratification among women with suspected preeclampsia, as well as among women at high risk for preeclampsia. Prediction of adverse outcomes in women, after the clinical diagnosis of preeclampsia, is also important. This report has been developed following a meeting of international experts and aims to guide clinicians in the management of pregnant women at risk of preeclampsia using the sFlt-1/PlGF ratio test.

Comparative analysis of the range list of medicines for the treatment of arterial hypertension in accordance with domestic and international clinical guidelines

Cardiovascular disease is the most common cause of death and disability worldwide. There are more than 12 million patients with hypertension in Ukraine. Timely prescription of medicines patients with AH in accordance with current clinical guidelines significantly improves the quality of life and survival of patients.
 The purpose of the study was to conduct a comparative analysis of the international and domestic range of modern medicines for the treatment of hypertension according to INN and ATC-classification and to investigate the status of their registration and inclusion in the reimbursement lists in Ukraine in order to determine the potential physical availability of drugs for the treatment of hypertension.
 An analysis of the domestic regulatory framework showed that international CG for the treatment of hypertension and national CPs can be used in Ukraine. The content analysis of the CG showed that international CG include classes of medicines for initial and maintenance therapy of hypertension: ACE inhibitors, ARBs, diuretics (thiazide and thiazide-like), calcium antagonists and beta-blockers, while preference is given to combinations of these drugs due to better adherence patients for treatment.
 It was found that according to the ATC classification, 41 ACE inhibitors and their combinations are represented on the international pharmaceutical market for the treatment of hypertension; of which 16 are single-component drugs, 25 are combined; ARB II and their combinations ‒ 32, single-component 10, combinations ‒ 22; calcium channel blockers and their combinations ‒ 21, single-component ‒ 18, combinations ‒ 2, thiazide diuretics ‒ 10, thiazide-like diuretics ‒ 11.
 An analysis of the status of registration in Ukraine according to certain INN and ATC classification showed that 56 drugs were registered, which is 48.69% of the possible 115 (drugs and ACE inhibitors and their combinations 22 (53.65%), ARBs II and their combinations 21 (65.63%); CCBs and their combinations ‒ 8 (38.10%); thiazide diuretics ‒ 1 (10%), thiazide-like diuretics ‒ 3 (27.27%)).

REVIEW OF RUSSIAN AND INTERNATIONAL CLINICAL GUIDELINES FOR THE MANAGEMENT IN PATIENTS WITH DIABETIC FOOT SYNDROME

The review presents an analysis of Russian and international clinical guidelines that may guide the doctor in their professional activities in the management of patients with diabetic foot syndrome and its prevention. The purpose of the work is an extended normative support for the decisions made by doctors in the diagnosis and detection of diabetic foot syndrome. Based on the results, an algorithm was developed to support decisions used by doctors in the diagnosis and treatment of patients with diabetic foot syndrome.

Historical aspects and modern concepts in the treatment of patients with differentiated thyroid cancer, refractory to radioactive iodine therapy

Radioiodine therapy for differentiated thyroid cancer has been used for a long time, mainly in patients of intermediate and high risk, as well as in the presence of distant metastases. However, about 30–40 % of patients are refractory to radioiodine therapy, which significantly worsens the prognosis. In patients with radioiodine-refractory differentiated thyroid cancer, therapy with targeted agents, primarily tyrosine kinase inhibitors, is indicated.This review addresses the criteria for refractoriness and criteria for prescription of targeted therapy, and presents the results of clinical studies of the targeted agents used. As of today, lenvatinib is the most well-known targeted agent. In particular. In SELECT trial lenvatinib demonstrated efficacy in terms of progression-free survival and overall survival in patients with radioiodine-refractory differentiated thyroid cancer. As a result, lenvatinib was included in the international and Russian clinical guidelines for the management of this group of patients as a drug of the 1st line of targeted therapy.

Improving the Time to Antibiotic Administration in Paediatric Febrile Neutropenia: Implementation of a Clinical Care Pathway in Saudi Arabia

The aim of this quality improvement practice project was to improve noted delays in the time to antibiotic administration in paediatric febrile neutropenic patients seen at King Faisal Specialist Hospital and Research Centre (KFSH&RC), Saudi Arabia. Larrabee’s 6-step Model for Change of evidence-based practice guided the project. Clinical audit, nursing knowledge survey, comprehensive literature and international clinical guideline review were used to identify and design a clinical care pathway for paediatric febrile neutropenic patients at KFSH&RC. Post-implementation clinical audit showed a reduction in time to antibiotic administration and increased self-efficacy and knowledge among nursing staff in relation to managing the care of febrile neutropenic patients. This reflects similar improvements seen internationally in other centres following the introduction of a clinical pathway. This nursing led practice change was the first of its kind for KFSH&RC. It demonstrated that with support from key stakeholders, Larrabee’s model for evidence- based practice change can be used for introducing a nurse-led clinical care pathway in Saudi Arabia. Highlights •A new clinical care pathway introduced in Saudi Arabia improved time to antibiotic administration in paediatric febrile neutropenic patients. •Implementing a nurse-led clinical care pathway increased nurses’ confidence with managing children with febrile neutropenia and the skills and knowledge related to the accessing and delivering medication via central access devices •With key local stakeholder support evidence-based change frameworks such as that proposed by Larrabee can be used to improve nursing management in Saudi Arabia.

Pediatric Prescriptions of Proton Pump Inhibitors in France (2009-2019): A Time-Series Analysis of Trends and Practice Guidelines Impact

To describe the ambulatory proton pump inhibitor (PPI) prescription in French children, its trends, and the impact of French (2014) and international (2018) clinical guidelines. We described PPI prescription rates based on national dispensation data in French children (IQVIA's Xponent database, 2009-2019). Using a segmented linear regression, we assessed the impact of clinical guidelines on PPI prescription rates. Analyses were performed for the overall pediatric population and by age subgroups (infants <2years old, children 2-11years old, adolescents 12-17years old). During the study period, 8 060 288 pediatric PPI prescriptions were filled, with a mean PPI prescription rate of 52.5 per 1000 inhabitants per year. Between 2009 and 2019, the PPI prescription rate increased by 41% in the overall pediatric population (+110% in infants). The PPI prescription rate showed seasonal patterns with peaks in winter. After the release of French guidelines, significant decreases in trends of prescription rates occurred overall (change in trend -0.28, 95% CI -0.34;-0.23) and across all age groups. In infants, this change in trend was not sufficient to reverse the PPI prescription rate that was still increasing over time. In children, the PPI prescription rate slightly decreased and in adolescents, it was stable. After the release of international guidelines, a significant decrease in trend occurred in adolescents only (change in trend -0.26, 95% CI -0.47; -0.04). The pediatric PPI prescription rate in France was high, displayed a major increase over the last decade, mainly among infants, and was modestly affected by clinical guidelines.

Current Screening Methods for the Risk or Presence of Malnutrition in Cancer Patients.

Malnutrition is highly common among cancer patients and is associated with a poor quality of life, increased treatment toxicities and decreased survival. The screening of malnutrition should be performed in an early stage of cancer disease and should be rapid, not expensive and highly sensitive to identify the risk of developing malnutrition. Importantly, international clinical guidelines suggest to perform screening for malnutrition in all cancer patients and if the risk is present, they recommend to perform a full nutritional assessment. During the screening phase, different nutritional parameters are considered including the loss of appetite, low food intake, body weight loss and burden of the disease. These items are present in several screening tools, such as the Nutrition Risk Screening (NRS)-2002, the Malnutrition Universal Screening Tool (MUST) and the Mini Nutritional Assessment (MNA) which represent the most widely used tools to screen for an altered nutritional status in cancer patients. Recently, the Global Leadership Initiative on Malnutrition (GLIM) developed an assessment tool for the diagnosis of malnutrition taking into account the presence of i) involuntary body weight loss, ii) body mass index, iii) low muscle mass, iv) low food intake and disease burden/inflammation; in particular, body weight loss, decreased body mass index (BMI), and low muscle mass are considered as phenotypic criteria, whereas reduced food intake, disease burden and inflammation are defined as etiologic criteria. To perform the diagnosis of malnutrition, GLIM consensus considered the presence of at least one phenotypic and one etiologic criterion. The above-mentioned screening tools were validated in different clinical settings and suggesting the use of one tool vs another is challenging considering, among others, different factors including the type and stage of cancer and the setting (i.e., inpatient or outpatient care). Recent data obtained among large cohorts of cancer patients indicate that personalized nutritional therapy reduced mortality risk and ameliorated quality of life and functionality among cancer patients with high nutritional risk, supporting the urgent need for implementing screening and diagnosis of malnutrition in this context.

Thiazide and thiazide-like diuretics: how to make the right choice?

Most patients with arterial hypertension (AH) require a combination treatment to achieve the goal blood pressure. According to Russian and international clinical guidelines on the treatment of AH patients, various antihypertensive drugs may be combined; however, not all combinations have similar profiles of safety and clinical efficacy. In this respect, special attention is given to combinations of renin-angiotensin-aldosterone system inhibitors and thiazide (hydrochlorothiazide) or thiazide-like (chlortalidone, indapamide) diuretics. Diuretics also differ in their mechanisms of action, presence of pleiotropic effects and organ-protective properties, effects on the prognosis, and in the evidence base. This review discusses the place of thiazide and thiazide-like diuretics in the treatment of patients with AH and provides an evaluation of major differences in pharmacological and clinical effects of drugs of the diuretic class.

Nutritional Practices in Critically Ill Patients – A Review

Nutrition therapy during critical illness has been a focus of recent research, with a lot of publications accompanied by two updated international clinical guidelines. There have been many trials with conflicting results making the translation of this evidence into practice challenging. This review article aims to provide clinicians with a comprehensive summary of the latest nutritional practices in critically ill patients.

La «Semana del Fósforo»: implicación de la nefrología española en el control de los valores plasmáticos de fósforo

BackgroundThe adequate control of phosphorus levels is a major concern for professionals involved in the care of patients with chronic kidney disease (CKD), since high phosphorus levels are directly related to an increase in mortality. ObjectivesTo know the perception and involvement of Spanish nephrologists on the control of phosphorus levels, the so-called “Phosphorus Week” was organized (November 13-17, 2017). MethodsAll members of the Spanish Society of Nephrology were invited to participate in an online survey, which included questions on aspects related to phosphorus control in patients with advanced CKD (aCKD) (glomerular filtration rate <30ml/min/1.73m2) and in the different modalities of renal replacement therapies (peritoneal dialysis [PD], hemodialysis [HD] and renal transplantation [KT]). Results72 data entries were obtained in the survey with an inclusion of 7463 patients. Of them, 35.4% were on HD, 34.8% were KT, 24.2% had aCKD and 5.5% were on PD. The serum phosphorus level target for the four groups of patients was 4.5mg/dl, with minimal variations depending on the area of the national territory. The patients with better control of phosphatemia were patients with KT (93.3% had phosphorus values <4.5mg/dl), followed by patients with aCKD (65.6% with phosphorus <4.5mg/dl). Only 53.6% of the patients on HD and 39.4% of those on PD reached the phosphorus goal <4.5mg/dl. The group of patients on dialysis was the one in whom phosphorus binders prescribed the most (73.5% and 75.6% in HD and PD, respectively), being less frequent in patients with patients with aCKD (39.9%) and only 4.5% in KT. ConclusionsThe objectives of the Spanish nephrologists are in line with those recommended by the national and international clinical guidelines; however, there is still a wide room for improvement to achieve these goals, especially in HD and PD patients.

Non-vitamin K Antagonist Oral Anticoagulants and Drug-Food Interactions: Implications for Clinical Practice and Potential Role of Probiotics and Prebiotics.

Non-vitamin K antagonist oral anticoagulants (NOACs) are a therapeutic option to prevent stroke in patients with atrial fibrillation (AF). In fact, NOACs have become the recommended choice by international clinical practice guidelines over vitamin K antagonists (VKA), because of their efficacy and safety profile, especially in newly initiated patients. The more predictable pharmacokinetic and pharmacodynamic profile of this family of drugs allows preventing anticoagulation drug monitoring. Furthermore, NOACs have significantly fewer drug and food interactions in comparison with VKAs. Despite this, there are no studies that compare the effects on the quality of anticoagulation of NOACs with the intake of potential interactions drugs of P-glycoprotein and cytochrome P450 (CYP). This review brings an overview of NOACs pharmacokinetics profile and their potential drug-food interactions. We also briefly discuss the potential role of prebiotics and probiotics in patients under therapy with NOACs.

Treatment recommendations for the management of persistent pelvic pain: a systematic review of international clinical practice guidelines.

Females with persistent pelvic pain (PPP) report great variability in the treatments recommended to them despite the availability of clinical practice guidelines (CPGs) that aim to standardise care. A clear consensus for the best practice care for PPP is required. To identify and summarise treatment recommendations across CPGs for the management of PPP, and appraise their quality. MEDLINE, CENTRAL, EMBASE, EmCare, SCOPUS, the Cochrane Database of Systematic Reviews, Web of Science Core Collection and relevant guideline databases were searched from their inception to June 2021. Included CPGs were those for the management of urogynaecological conditions in adult females published in English, of any publication date, and endorsed by a professional organisation or society. We screened 1379 records and included 20 CPGs. CPG quality was assessed using The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Descriptive synthesis compiled treatment recommendations across CPGs. The CPGs for seven conditions provided 270 individual recommendations. On quality appraisal, guidelines on average scored 'excellent' for the domains 'scope and purpose' (80.6%, SD=13.3) and 'clarity and presentation' (74.4%, SD=12.0); for other domains, average scores were satisfactory or poor. Four guidelines (for Endometriosis: NICE, RANZCOG and ESHRE; for polycystic ovary syndrome: Teede et al. 2018, International Evidence Based Guideline for the Assessment and Management of Polycystic Ovary Syndrome, Monash University, Melbourne, Australia) were deemed recommended for use. Recommendations were most frequent for pharmaceutical and surgical interventions. Recommendations were variable for psychological, physiotherapy and other conservative interventions. The quality of CPGs for PPP is generally poor. Several CPGs endorse the consideration of biopsychosocial elements of PPP. Yet most recommend pharmaceutical, surgical and other biomedical interventions.

The current state of the problem with the diagnosis and treatment of allergic rhinitis in pediatric practice

Among all allergic diseases in pediatric practice, allergic rhinitis is one of the most common pathologies of the upper respiratory tract. This review deals with the problem of modern principles for the diagnosis and treatment of allergic rhinitis in children based on the analysis of literature sources using electronic databases PubMed, Web of Science, MedLine, the Cochrane Library. Allergic rhinitis is an important medical and social problem of our time the importance of which has increased significantly in recent years. The growing number of people sensitized to pollen, the variety of symptoms and the negative impact on the quality of life of patients make pollen allergy one of the major problems in pediatrics. Despite the development of international national protocols and clinical guidelines, in many countries the control of allergic rhinitis in children remains insufficient. Therefore, it is necessary to take into account the individual characteristics of patients, pay attention to both nasal and extranasal symptoms, consider all pathognomonic diagnostic aspects, because the underdiagnosis of this allergic disease leads to inadequate therapy, complications, more severe atopy and reduced quality of children’s life in general. Recently, there is growing evidence of the need for personalized selection of the most effective therapy for allergic rhinitis in children. In-depth study of the pathogenetic role of circadian molecular clock in children with seasonal allergic rhinitis using informative molecular genetic methods may allow characterizing in detail the mechanism of regulation of allergic inflammation of the upper airway mucosa and evaluating the role of circadian genes in the development of allergic diseases, in particular allergic rhinitis. In the future, these studies may become an alternative to improve control over the course of allergy and the organization of a comprehensive monitoring system, development of new strategies for the treatment and prevention of allergic rhinitis in children.

Surgical approach for small bowel obstruction in the Russian Federation. National survey of surgeons

To study surgical approach for small bowel obstruction (SBO) regarding national and international guidelines. Considering literature data, national and international guidelines and clinical practice, we have formulated 15 questions regarding surgical approach for non-neoplastic SBO. Questions were sent by e-mail to the members of the Russian Society of Surgeons. Survey lasted 60 days. We used the program that provides the respondent with the possibility of visual control of survey results. Survey results were compared with national and international clinical guidelines, Russian- and English-language scientific publications. Restriction of the number of votes >1 and identification of respondents were not provided by the program. There was no reward for survey. A summary is provided on the main issues. There were 557 respondents (3.0% of surgeons in the Russian Federation). We obtained 481-620 answers for each question. This study is a valuable tool for primary assessment of current surgical practice for SBO in the Russian Federation. Study design did not imply conclusions on the optimal strategy based on opinions of majority of respondents. According to our survey, a significant number of respondents use the treatment strategy that differ from clinical guidelines. Their approach is based on their own clinical experience and local guidelines for the treatment of SBO. Less than half of the answers matched to national clinical guidelines, less than 10% - to the WSES guidelines. Despite the formal coincidence of some statements in national clinical guidelines and English-language recommendations, significant nonconformities require scientific discussion.

An excursion into ocular tuberculosis

Till today, ocular tuberculosis (OTB) presents clinicians with significant challenges in diagnosis and management. There is no one-size-fits-all approach to a heterogeneous disease like OTB, and clinicians often have to consider a multitude of factors when initiating treatment, such as tuberculosis endemicity, the probability of a true OTB diagnosis in the setting of nonspecific ocular features, the effective duration of treatment, and the likelihood of vision-threatening complications in the patient. It is no wonder that treatment protocols are widely varied globally. There have been recent developments in the standardization of nomenclature and therapeutic strategies for OTB, as established by the Collaborative OTB Study Working Group. In this review, we referred to findings in retrospective studies, international clinical guidelines, and OTB consortiums, to explore the clinical presentations, investigations, and updated management principles for patients with presumed tubercular uveitis.

Efficacy Predictors of the Third-Line Tyrosine Kinase Inhibitor Therapy in Patients with Chronic Phase of Chronic Myeloid Leukemia: Results of a Multi-Center Study

Background. The introduction of tyrosine kinase inhibitors (TKIs) into real-world clinical practice considerably improved the prognosis for patients with chronic myeloid leukemia (CML). However, during long-term follow-up, almost 1/2 and 2/3 of patients in the chronic phase (CP) discontinue TKI therapy of the first or second line, respectively. According to the Russian and International clinical guidelines, the third-line therapy should include allogeneic hematopoietic stem cell transplantation (allo-HSCT). And yet, some patients on the third-line therapy achieve and sustain optimal response on long-term TKI administration. Up to now, no clear-cut prognostic factors of TKI efficacy in the third-line therapy have been identified. This creates a challenge for treatment decision making after the failures of two lines of TKI therapy. Aim. To assess the efficacy of the third-line TKI therapy in real-world clinical practice and to identify the factors affecting the long-term therapy outcomes in CML-CP. Materials &amp; Methods. The retrospective study enrolled 73 CML-CP patients aged &gt; 18 years, treated with TKIs in the third-line at 5 specialized institutions in Saint Petersburg and Leningrad Region. Among the patients there were 26 men (35 %). The median age of the patients was 51 years (range 25-88 years). Results. With the median (range) third-line TKI therapy duration of 14 (1-120) months, the rate of complete cytogenetic response (CCR) was 30 % (п = 22) in the total cohort. The median time before achieving CCR was 9 (4-25) months. With the median follow-up time from the beginning of third-line TKI therapy till the last visit of 25 (3-136) months, progression to accelerated phase or blast crisis was observed only in 13 (17 %) out of 73 patients. Death was reported in 26 % (n = 19) of cases, among them 5 patients whose death was not CML-associated. At the last visit, 13/73 (18 %) patients were still on third-line TKI therapy. Direct and longterm therapy outcomes, including achievement of CCR and assessment of overall and progression-free survivals, were significantly better in patients with any cytogenetic response (CR) than in those without it or without complete hematologic response. Conclusion. The implementation of TKIs in the third-line CML-CP therapy seems to be suitable for patients with at least some CR, especially if an optimal donor of hematopoietic stem cells is unavailable or if the risk of severe allo-HSCT complications is too high.

Innovative technologies and multimodal correction in medical rehabilitation of motor and neuropsychological disturbances due to stroke

The article presents an overview of innovative technologies based on the methods of sensorimotor retraining of the patient using various types of biofeedback (BFB) as the most promising in the medical rehabilitation (MR) of patients with cerebral stroke (CS). The works of a high level of evidence (RCTs, national and international clinical guidelines, meta-analyses, systematic reviews) of the Medline, Pubmed, PubMed Cochrane Library databases are analyzed, ClinicalTrials.gov. It is emphasized that training with multisensory effects on visual, auditory, vestibular and kinesthetic analyzers have a beneficial effect on cognitive-motor training and retraining, neuropsychological status of the patient and increase the level of motivation to achieve success in the rehabilitation process. The synergy of multimodal effects of digital technologies, BFB, virtual reality, and the brain-computer interface will expand the capabilities and improve the efficiency of MR of after stroke-patients.

Management of Colorectal Cancer with Synchronous Liver Metastases: A Systematic Review of National and International Clinical Guidelines (CoSMIC-G)

Introduction: The World Health Organization’s (WHO) Health Research Advisory Committee recommends that evidence informs best practice. This study systematically reviews national guidelines for the management of patients with colorectal cancer with a specific focus on the advice for patients with synchronous liver-limited or liver-dominant metastases. Methods: This is a systematic review of clinical guidelines for the management of colorectal cancer with a specific focus on the advice for patients with synchronous liver metastases. The National Library of Medicine PubMed database was queried for metastatic colorectal cancer guidelines using the keywords “colorectal cancer”, “liver” and “guidelines”. Studies are included if they are national guidelines on the management of patients with colorectal cancer. The study period for inclusion is the ten year period from January 2011 to January 2021. The protocol was registered with PROSPERO (registration number CRD42021243744). Results: Searches returned 302 unique articles of which nineteen were colorectal cancer and/or metastatic colorectal cancer guidelines. For the purposes of this report, the 7 guidelines of the NCCN (USA), NICE (UK), France, Spain, Japan, China and Australia are included. Five (72%) recommend against routine use of FDG-PET for staging. All guidelines support neoadjuvant chemotherapy as the first treatment. Two (29%) support liver surgery as first step. Six support and 1 discourage synchronous surgery. Hepatic criteria for synchronous are defined in 2 (29%) and primary tumour criteria in 2 (29%). Conclusion: There is substantial variation between international guidelines on recommendations for the management of patients with colorectal cancer and synchronous liver metastases.