International Clinical Practice Guidelines Research Articles

Application of the 2022 American Thoracic/European Respiratory Society/Japanese Respiratory Society/Associatión Latinoamericana de Tórax (ATS/ERS/JRS/ALAT) idiopathic pulmonary fibrosis and progressive pulmonary fibrosis clinical practice guideline to a Canadian population: An opinion piece

In 2022, the American Thoracic Society (ATS), European Respiratory Society (ERS), Japanese Respiratory Society (JRS), and Associatión Latinoamericana de Tórax (ALAT) produced an updated clinical practice guideline on the diagnosis and management of idiopathic pulmonary fibrosis (IPF), also defining and making treatment recommendations for progressive pulmonary fibrosis (PPF). In this review, we summarize and highlight aspects of this guideline that are most relevant to Canadians. New recommendations in IPF include the use of transbronchial lung cryobiopsy as an alternative to surgical lung biopsy and a recommendation against antacid medications in asymptomatic patients. The guideline also recommends treating PPF with nintedanib, an antifibrotic currently approved for IPF. The guideline definition of PPF should be adopted in Canada, although with flexibility in physiologic parameters of the PPF definition and increased support for community respirologists to care for these patients. Although pirfenidone was not recommended in the guideline for the treatment of PPF, there are multiple clinical trials that support its use as a second-line treatment for PPF. It is imperative that Canadian resources continue to support knowledge generation of this complex group of patients and that Canadians continue to have ongoing involvement in the development of future international clinical practice guidelines.

Optimal hemodynamic parameters for risk stratification in acute pulmonary embolism patients.

Hemodynamic assessment of patients with pulmonary embolism (PE) remains a fundamental component of early risk stratification that in turn, influences subsequent monitoring and therapeutic strategies. The current body of literature and international evidence-based clinical practice guidelines focus mainly on the use of systolic blood pressure (SBP). The accuracy of this single hemodynamic parameter, however, and its optimal values for the identification of hemodynamic instability have been recently questioned by clinicians. For example, abnormal SBP or shock index may be a late indicator of adverse outcomes, signaling a patient in whom the cascade of hemodynamic compromise is already well underway. The aim of the present article is to review the current evidence supporting the use of SBP and analyze the potential integration of other parameters to assess the hemodynamic stability, impending clinical deterioration, and guide the reperfusion treatment in patients with PE, as well as to suggest potential strategies to further investigate this issue.

From the experience of more than 1000 glue ablation procedures for varicose veins: how to do it

Cyanoacrylate adhesive closure (CAC) is currently one of the main non-thermal ablation modalities of incompetent saphenous veins. High efficacy and safety of the method is supported by international clinical practice guidelines as well as the real-world practice. In contrast to thermal ablation, CAC is advantageous in terms of low periprocedural pain and bruising, fast procedure time and postprocedural recovery, high patient comfort and satisfaction rates as well as avoidance of postprocedural compression. This publication summarises the practical tips and tricks of glue ablation procedure based on 5-year experience (2019–2023) at the “SM-Clinic” Phlebology Centre, Moscow. Indications for the preferred use of CAC are formulated, such as: low pain threshold; contraindications (or unwillingness) to postprocedural compression; extensive comorbidity and fragile patients; concomitant morbid obesity; the presence of axial reflux along the saphenous veins; the need for simultaneous ablation of several incompetent truncal veins; below-the-knee incompetence of saphenous veins, including recurrent varicose veins; extensive lipodermatosclerosis and/or venous leg ulcer; patient’s HIV and viral hepatitis positive status. A step-by-step interventional protocol of glue ablation is described, including the modified protocols of the procedure. The immediate and long-term outcomes of the CAC according to current data are discussed. Special attention is paid to adverse events following CAC, as well as technical aspects of their prevention. Despite high efficacy and safety profile, today’s limitations for adoption and wider use of CAC are cost issues and lack of reimbursement.

Frailty recommendations and guidelines. An evaluation of implementability and critical appraisal of clinical applicability by the ISPRM Frailty Focus Group

Objective: Aging is associated with an increased burden of multimorbidity and disease-related functional loss and disability, widely impacting patients and health care systems. Frailty is a major factor in age-related disability and is an important target for rehabilitation interventions, considering that is a reversible condition. Methods: A working group of members of the International Society of Physical Medicine and Rehabilitation, responding to the World Health Organization (WHO) 2030 call for action to strengthen rehabilitation, was established to assess the quality and implementability of the existing guidelines for the rehabilitation of frailty. Guidelines were retrieved using a systematic search on Pubmed, Scopus, and Web of Science and from the reference lists of screened articles. The included guidelines were evaluated using the AGREE II to assess their quality and using the AGREE-REX to assess their clinical credibility and implementability. Guidelines with a score >4 in the AGREE II item evaluating the overall quality of the guideline were considered for endorsement. Finally, 9 external reviewers evaluated the applicability of each recommendation from the endorsed guidelines, providing comments about the barriers and facilitators for their implementation in their country. Results: Ten guidelines were retrieved and evaluated by the working group, of which 4 guidelines, that is, the WHO Guidelines on Integrated Care for Older People, the FOCUS guidelines, the Asia-Pacific Clinical Practice Guidelines for the Management of Frailty, and the ICFSR International Clinical Practice Guidelines for Identification and Management of Frailty, were considered for endorsement. All these guidelines were rated as of adequate quality and implementability. Conclusion: The WHO Guidelines on Integrated Care for Older People (24), the ICFSR International Clinical Practice Guidelines for Identification and Management of Frailty (15), the FOCUS guidelines (25), and the Asia-Pacific Clinical Practice Guidelines (14) for the Management of Frailty have the best quality and applicability of the existing guidelines on the management of frailty, we suggest that should be employed to define the standards of care for patients with frailty. There are barriers to their implementation, as stated by our experts, to take into account, and some of them are country or region-specific. Screening for frailty, exercise, nutrition, pharmacological management, social and psychological support, management of incontinence, and overall comprehensive clinical management are the best tools to face frailty.

Axial spondyloarthritis guidelines - aiming for maximum impact.

This review discusses international clinical practice guidelines (CPGs) for axial spondyloarthritis (axSpA) focusing on methodology, guideline quality, and implementation. The Assessment of SpondyloArthritis International Society/European Alliance of Associations for Rheumatology (ASAS/EULAR) and Pan-American League of Associations for Rheumatology (PANLAR) recently published axSpA CPGs and updates of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network (ACR/SAA/SPARTAN) and Asia-Pacific League of Associations for Rheumatology (APLAR) CPGs are expected. GRADE has emerged as the dominant framework for CPG development and has been used by three of the four international axSpA guidelines. Notable differences exist among these guidelines in the way that the recommendations are presented. Two of the four acknowledge the need for implementation strategies, but little detail about this is provided. The few studies that have evaluated the implementation of axSpA CPGs have identified poor adherence to recommendations on physical therapy/exercise and disease activity monitoring. Implementation science has identified many barriers and facilitators affecting guideline uptake, including those related to healthcare professionals and to the guidelines themselves. Creation of a tailored implementation plan simultaneously with the CPG is recommended. While methodological rigor in the creation of evidence-based recommendations is the focus of CPG development, recommendations must be presented in a user-friendly format that makes them easy to apply. 'Living guidelines' could facilitate keeping content up to date. Implementation is critical for the success of a CPG and should be emphasized in future axSpA guideline updates. Further research is needed to better understand the factors impacting the successful implementation of axSpA CPGs.

Guideline for the diagnosis and management of multiple myeloma-related renal impairment (2024 version)

Renal impairment is a common complication of multiple myeloma (MM). All patients with MM should be assessed for the presence and severity of renal impairment. The clinicopathological manifestations of MM-related renal impairment are diverse and complex; accordingly, except for light-chain nephropathy, which can often be diagnosed without biopsy based solely on clinical criteria, a renal biopsy is needed for an accurate diagnosis. Supportive care, such as adequate hydration, is required for all patients with MM-related renal impairment. The guideline provide the principles for dose adjustment of the drugs used for MM with renal impairment, including proteasome inhibitors, immunomodulators, monoclonal antibodies, small molecule inhibitors, and alkylating agents, as well as those used for myeloma bone disease. Autologous stem cell transplantation (ASCT) and chimeric antigen receptor T-cell immunotherapy (CAR-T) are effective in patients with moderate renal impairment and are tolerated by the patients. The Chinese Hematology Association; the Chinese Geriatrics Association, Society of Hematology; and the Chinese Research Hospital Association, Society of Nephrology asked experts to collate information on current progress in clinical research relating to MM with renal impairment. This guideline was developed based on the gathered data combined with the latest international consensus and clinical practice guidelines.

Frailty recommendations and guidelines: an evaluation of the implementability and a critical appraisal of clinical applicability by the ISPRM Frailty Focus Group.

Aging is associated with an increased burden of multi-morbidity and disease related functional loss and disability, widely impacting patients and health care systems. Frailty is a major actor in age-related disability and is an important target for rehabilitation interventions, considering that is a reversible condition. A working group of members of the ISPRM, responding to WHO 2030 call for action to strengthen rehabilitation, was established to assess the quality and implementability of the existing guidelines for the rehabilitation of frailty. Guidelines were retrieved using a systematic search on Pubmed, Scopus and Web of Science and from the reference lists of screened articles. The included guidelines were evaluated using the AGREE II to assess their quality and using the AGREE-REX to assess their clinical credibility and implementability. Guidelines with a score >4 in the AGREE II item evaluating the overall quality of the guideline were considered for endorsement. Finally, nine external reviewers evaluated the applicability of each recommendation from the endorsed guidelines, providing comments about the barriers and facilitators for their implementation in their country. Ten guidelines were retrieved and evaluated by the working group, of which four guidelines, i.e. the WHO Guidelines on Integrated Care for Older People, the FOCUS guidelines, the Asia-Pacific Clinical Practice Guidelines for the Management of Frailty and the ICFSR International Clinical Practice Guidelines for Identification and Management of Frailty, were considered for endorsement. All these guidelines were rated as of adequate quality and implementability. The WHO Guidelines on Integrated Care for Older people (24) the ICFSR International Clinical Practice Guidelines for Identification and management of Frailty (15), the FOCUS guidelines (25) and the Asia Pacific Clinical Practice Guidelines (14) for the Management of Frailty have the best quality and applicability of the existing guidelines on the management of frailty, we suggest that should be employed to define the standards of care for patients with frailty. There are barriers for their implementation, as stated by our experts, to take into account, and some of them are country- or region-specific. Screening for frailty, exercise, nutrition, pharmacological management, social and psychological support, management of incontinence, and an overall comprehensive clinical management are the best tools to face upon frailty.

Abstract 2351: Genomics annotation and interpretation in somatic oncology using structured data from a clinical knowledgebase

Abstract Accurate and comprehensive interpretation of genomic variants has become a bottleneck in clinical sequencing applications due to the accelerating precision oncology and biomedical information explosion. This motivated us to build Ephesus, a framework enabling curation of predictive, prognostic and diagnostic evidence for clinical biomarkers in cancers. Currently Ephesus is the primary content source for Roche navify Mutation Profiler (nMP). The Ephesus’ data model ensures adherence to best practices in clinical genomic content curation. Variant classification follows the AMP guidelines for somatic variant interpretation. Variant interpretations are derived from international regulatory approvals and clinical practice guidelines (FDA, EMA, TGA, eVIQ, etc.) and recommendations (NCCN, ESMO). The data model is mapped to a set of relational tables. To enforce data integrity and validity, strategies such as data normalization based on standard nomenclatural ontologies, a submit-review-approval workflow, and biological constraints are adopted. Ephesus is deployed as a web application used by curators inside and outside Roche. The UI allows users to conduct edits, filtering, sorting and bulk operations on entities by attributes. In order to minimize manual effort and maximize content coverage, inference rules are applied before ingesting into nMP. Currently Ephesus is developed for data collection, browsing and summarizing primary entities such as biomarkers, evidence items, genes, variants, variant groups, and drugs. The content from the 2023-Aug snapshot contains 11,596 directly curated biomarker profiles (including biomarker combinations), and 6M+ expanded profiles for 41 major cancer types. To evaluate the clinical reporting value of the curated knowledge, ~160k real cancer patient samples of the AACR GENIE project were queried on Ephesus. Compared with three other major knowledgebases, Ephesus/NMP is observed showing the highest performance. Table 1. Percentage of patients or biomarkers with at least one interpretation from each knowledgebase CGI (2022-10-17) CIVIC(2023-09-01) ClinVar(2023-09-09) NMP(2023-08-11) AACR-Genie-v14.0 Total patient % with any interpretation 25% (40,545) 46% (73,835) 81% (130,882) 89% (142,905) 160,965 biomarker % (including combos) with any interpretation 0.03% (256) 0.06% (526) 13.26% (122,424) 73.79% (681,128) 923,093 Citation Format: Jian Li, Lili Niu, Shuba krishna, Fnu Kinshuk, Martin Jones, Carlos Hernandez, Michael Clark, Sandra Balladares. Genomics annotation and interpretation in somatic oncology using structured data from a clinical knowledgebase [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2351.

Are international guideline recommendations for the management of placenta accreta spectrum applicable in low- and middle-income countries?

The aim of this study was to explore how obstetricians-gynecologists in low- and middle-income countries (LMICs) can apply current international clinical practice guidelines (CPGs) for the management of placenta accreta spectrum (PAS) in limited resource settings. This was an observational, survey-based study. Clinicians with expertise in managing patients with PAS in LMICs were contacted for their evaluation of the recommendations included in four PAS clinical practice guidelines. Out of the 158 clinicians contacted, we obtained responses from 65 (41.1%), representing 27 middle income countries (MICs). The results of this survey suggest that the care of PAS patients in middle income countries is very different from what is recommended by international CPGs. Participants in the survey identified that their practice was limited by insufficient availability of hospital infrastructure, low resources of local health systems and lack of trained multidisciplinary teams (MDTs) and this did not enable them to follow CPG recommendations. Two-thirds of the participants surveyed describe the absence of centers of excellence in their country. In over half of the referral hospitals with expertise in managing PAS, there are no MDTs. One-third of patients with intraoperative findings of PAS are managed by the team initially performing the surgery (without additional assistance). The care of patients with PAS in middle income countries frequently deviates from established CPG recommendations largely due to limitations in local resources and infrastructure. New practical guidelines and training programs designed for low resource settings are needed.

BRAF-Mutated Melanoma Journey in Latin America: Expert Recommendations From Diagnosis to Treatment.

• Gather a panel of Latin American experts in testing and treating BRAF-melanoma. • Describe the current landscape of BRAF-mutated melanoma in Latin America. • Outline the current gaps in testing and recommend improvements for testing and treating BRAF-mutated melanoma in the region. Melanoma prevalence in Latin America is lower than in high- and middle-income countries. However, recent data indicate that the region's incidence and mortality are rising, with more stage IV patients being diagnosed. According to international clinical practice guidelines, conducting BRAF-mutation testing in patients with stage III or stage IV melanoma and high-risk resected disease is imperative. Still, BRAF-mutation testing and targeted therapies are inconsistently available in the region. Americas Health Foundation convened a meeting of Latin American experts on BRAF-mutated melanoma to develop guidelines and recommendations for diagnosis through treatment. Some recommendations for improving diagnostics through improving access and reducing the cost of BRAF-mutation testing, enhancing efficiency in pathology laboratories, and creating country-specific local guidelines. The panel also gave treatment recommendations for neo-adjuvant therapy, adjuvant therapy, and therapy for patients with metastatic disease in Latin America.

State of the science: Eye movement desensitization and reprocessing (EMDR) therapy.

Eye movement desensitization and reprocessing (EMDR) therapy is an evidence-based psychotherapy for posttraumatic stress disorder (PTSD), with support from more than 30 published randomized controlled trials (RCTs) demonstrating its effectiveness in both adults and children. Most international clinical practice guidelines recommend EMDR therapy as a first-line treatment for PTSD. This paper describes the current state of the evidence for EMDR therapy. We begin with a brief description of EMDR therapy and its theoretical framework. Next, we summarize the scientific support for its efficacy, effectiveness, and safety and discuss its applicability across cultures and with diverse populations. We conclude with suggestions for future directions to develop the research base and applications of EMDR therapy.

N32 Implementation of chromoendoscopy in colorectal cancer screening in patients with Inflammatory Bowel Disease

Abstract Background Patients with inflammatory bowel disease (IBD) have a higher risk of colorectal cancer (CRC), so we must implement the best available endoscopic technique to detect it early, decreasing the risk of CRC and death. There is low adherence to CRC screening by chromoendoscopy with dye in patients with IBD, despite the fact that national and international clinical practice guidelines consider this technique of choice based on the available evidence. Description Of The Initiative The standardization of a screening procedure, based on the evidence of endoscopy, allows any member of the team, doctor or nurse, to detect the need for the indication, improving screening in terms of follow-up interval and technique. Likewise, the inflammatory nurse will have to know the technique to be able to inform the patient and improve their adherence, preparation and resolve doubts. The main aim is early detection of dysplasia and CRC. The side aims are: ▪ To improve the implementation of chromoendoscopy as a technique for CRC screening. ▪ Improve patient adherence to colonoscopy. Methods The development of an endoscopic follow-up procedure according to risk factors in patients with ulcerative colitis and colonic Crohn's disease, in which chromoendoscopy is the technique of choice. The technique in our center is with 0.4% carmine indigo diffusion with catheter-diffuser, but it is possible to adapt other alternatives according to availability. The procedure establishes the follow-up interval at 1, 3 or 5 years depending on the low, medium or high risk, respectively, depending on the activity, extent and duration of the disease, presence of stenosis and pseudopolyps, primary sclerosing cholangitis and/or family history of CRC. Results In our center, 100% of screenings are performed by chromoendoscopy with dye, by a single expert endoscopist, scheduled with a longer examination time than a conventional colonoscopy and with optimization of bowel preparation. Conclusion CRC screening of patients with IBD should preferably be performed with chromoendoscopy with dye, establishing follow-up intervals depending on known risk factors, both clinical, endoscopic and histological, and this indication should be standardized in a procedure that is known to all members of the team.

The role of an artificial intelligence model in antiretroviral therapy counselling and advice for people living with HIV.

People living with HIV may find personalized access to accurate information on antiretroviral therapy (ART) challenging given the stigma and costs potentially associated with attending physical consultations. Artificial intelligence (AI) chatbots such as ChatGPT may help to lower barriers to accessing information addressing concerns around ART initiation. However, the safety and accuracy of the information provided remains to be studied. We instructed ChatGPT to answer questions that people living with HIV frequently ask about ART, covering i) knowledge of and access to ART; ii) ART initiation, side effects, and adherence, and iii) general sexual health practices while receiving ART. We checked the accuracy of the advice against international HIV clinical practice guidelines. ChatGPT answered all questions accurately and comprehensively. It recognized potentially life-threatening scenarios such as abacavir hypersensitivity reaction and gave appropriate advice. However, in certain contexts, such as specific geographic locations or for pregnant individuals, the advice lacked specificity to an individual's unique circumstances and may be inadequate. Nevertheless, ChatGPT consistently re-directed the individual to seek help from a healthcare professional to obtain targeted advice. ChatGPT may act as a useful adjunct in the process of ART counselling for people living with HIV. Improving access to information on and knowledge about ART may improve access and adherence to ART and outcomes for people living with HIV overall.

FLOW: Flow dysfunction of hemodialysis vascular access: A randomized controlled trial on the effectiveness of surveillance of arteriovenous fistulas and grafts.

It is assumed that identification and correction of asymptomatic stenoses in the vascular access circuit will prevent thrombosis that would require urgent intervention to continue hemodialysis treatment. However, the evidence base for this assumption is limited. Recent international clinical practice guidelines reach different conclusions on the use of surveillance for vascular access flow dysfunction and recommend further research to inform clinical practice. The FLOW trial is a double-blind, multicenter, randomized controlled trial with a 1:1 individual participant treatment allocation ratio over two study arms. In the intervention group, only symptomatic vascular access stenoses detected by clinical monitoring are treated, whereas in the comparison group asymptomatic stenoses detected by surveillance using monthly dilution flow measurements are treated as well. Hemodialysis patients with a functional arteriovenous vascular access are enrolled. The primary outcome is the access-related intervention rate that will be analyzed using a general linear model with Poisson distribution. Secondary outcomes include patient satisfaction, access-related serious adverse events, and quality of the surveillance process. A cost effectiveness analysis and budget impact analysis will also be conducted. The study requires 828 patient-years of follow-up in 417 participants to detect a difference of 0.25 access-related interventions per year between study groups. As one of the largest randomized controlled trials assessing the clinical impact of vascular access surveillance using a strong double-blinded study design, we believe the FLOW trial will provide much-needed evidence to improve vascular access care for hemodialysis patients.

Management of evidence and conflict of interest in guidelines on early childhood allergy prevention and child nutrition: study protocol of a systematic synthesis of guidelines and explorative network analysis.

With the rising prevalence of allergic diseases in children, prevention of childhood allergies becomes an important public health issue. Recently, a paradigm shift is taking place in the approach to preventing allergies, and clinical practice guidelines (CPG) and food-based dietary guidelines (FBDG) play an important role in providing practitioners with the latest evidence and reliable guidance. However, concern about the methodological quality of the development of FBDGs and CPGs, including limitations in the systematic reviews, lack of transparency and unmanaged conflicts of interest (COI), reduce the trust in these guidelines. We aim to synthesize the available guidance on early childhood allergy prevention (ECAP) through a systematic search for national and international CPGs and FBDGs concerning ECAP and child nutrition (CN) and to assess the quality of the guidelines and management of COI. Additionally, we will analyse the content and the evidence base of the recommendation statements. We aim to quantify the COI in guideline panellists and explore possible associations between COI and recommendations. Through a social network analysis, we expect to elucidate ties between panellists, researchers, institutions, industry and other sponsors. Guidelines are an important tool to inform healthcare practitioners with the newest evidence, but quality and reliability have to be high. This study will help identify potential for further improvement in the development of guidelines and the management of COI. If the social network analysis proves feasible and reveals more information on COI in comparison to disclosed COI from the previous analyses, the methodology can be developed further to identify undisclosed COIs in panelists. This research does not require ethical approval because no human subjects are involved. Results will be published in international peer-reviewed open access journals and via presentations at scientific conferences.

Guidelines of integrated Chinese and western medicine for diagnosis and treatment of chronic obstructive pulmonary disease (2022).

Chronic obstructive pulmonary disease (COPD), with high prevalence rate, mortality, disability rate, and heavy disease burden, has become a critical chronic disease seriously threatening public health worldwide. Traditional Chinese medicine and Western medicine both have shown advantages in diagnosing and treating COPD, which has been widely applied in the clinics. In order to improve the diagnostic and treatment level for COPD with integrated traditional Chinese and Western medicine, the Guidelines of Integrated Chinese and Western Medicine for Diagnosis and Treatment of COPD were developed by the Internal Medicine Committee of the World Federation of Chinese Medicine Societies. First, a multidisciplinary working group was established. Development methods and processes of international clinical practice guidelines were adopted in the whole research. In final, a total of 13 recommendations for the diagnosis and treatment of COPD were established based on available evidence with the best quality. Meanwhile, characteristics of integrated traditional Chinese and Western medicine in treating COPD were taken into account with pros and cons of each intervention. The guidelines could be used as a reference for physicians in respiratory medicine departments (traditional Chinese medicine, integrated traditional Chinese and Western medicine, and Western medicine) at various levels of medical institutions in their diagnosis and treatment.

Main Treatment Choices in the 2 First Lines of Therapy for Multiple Myeloma in Patients with High Risk Cytogenetics: Lesson from the Real World in the EU5 Countries and the USA

Background Typical approach to initial therapy in multiple myeloma (MM) includes more aggressive combinations early on with triplets. To further improve response rates and survival, quadruplets are moving to frontline, in both stem cell transplant (SCT) eligible and ineligible patients (pts). Defining high risk features is crucial; current international NCCN and IMWG clinical practice guidelines stratify pts based on those criteria proposing more aggressive therapy in this setting. Definitions of high risk are: cytogenetic abnormalities incl. del(17p), some laboratory factors with ISS III and increased LDH, some clinical features including plasma cell leukaemia, extramedullary involvement or age and functional assessment with primary refractory disease and rapid progression within 18 months of diagnosis. Aims Identify in real world setting the main regimens used in first line SCT eligible and ineligible pts as well as in 2nd line high risk pts with MM in EU5 countries (France, Germany, Italy, Spain, UK) and in the USA. Methods Anonymous patient charts were analysed based on data reported by onco-haematologists treating MM pts in EU5 countries and USA. A total of 1,575 unique patient charts in 1st line (530 SCT eligible and 1,045 SCT ineligible pts) and 1,665 unique pts in 2nd line were included in the analysis, from Oct. to Dec. 2022. The analysis focused on pts with high risk cytogenetic features and regimens used in accordance with international clinical practice guidelines. D= daratumumab; V=bortezomib; T=thalidomide; d= dexamethasone; R=lenalidomide; M= melphalan; p= prednisone; K=carfilzomib; Isa=isatuximab Results Mean age in 1st line SCT eligible pts was 59.0 years (n=441) in EU5 and 60.9 years (n=89) in the USA. In 1st line SCT ineligible pts, mean age was 74.0 years (n=838) in EU5 and 65.9 years (n=207) in the USA. Among all 1st line SCT eligible pts, 34% in EU5 and 29% in US had high risk cytogenetic features, with del17p identified in 12% of EU5 cases and 16% of US cases. In 1st line SCT ineligible pts in the EU5 and in the US 14% and 17% respectively were high risk, including 9% and 13% del17p. In the 2nd line setting, 1,208 unique pts were included in the EU5 and 457 in the US with 17% and 14% classified at high risk, respectively, del17p was identified in 9% and 11% of pts. The most frequently used regimens in 1st line SCT eligible pts in EU5 are D-VRd (n=56), VRd (n=69) and D-VTd (n=136) with 41% and 39% of high-risk pts. In the US, the most frequent regimens used in this subset were D-VRd (n=17) and VRd (n=33) with 35% and 39% of pts belonging to the high-risk group. For 1st line SCT ineligible pts in EU5, 40% of patients were high risk, with the most common regimen being VRd (n=67). Pts with del17p were also overrepresented in this subgroup with 15% of total population receiving VRd. Other frequently used regimens were D-VMP (n=95), DRd (n=188), Rd (n=148) and VMP (n=80) but none was preferred in high-risk pts. In the US, the most frequently-used regimen in 1st line SCT ineligible population was VRd (n=73) with 27% of pts with high-risk features (vs. 17% in the overall population). For 2nd line treatment in the EU5, carfilzomib-based combinations are more frequently used in high-risk pts, particularly DKd (n=42) and KRd (n=118), both associated with 35% of pts with high-risk features. Kd was also regularly used in this subset (n=76) with 32% of high-risk pts. Despite a small number of pts (n=29), Isa-Kd triplet is more regularly used in pts with del17p (21% of all pts). In 2nd line setting in the USA, the most frequently used regimen was DKd (n=37) with 30% high-risk pts. In pts with del17p, Kd was regularly used (n=14) with 21% of pts presenting this abnormality. Among other regimens, such as DPd (n=38), Dd (n=30), DRd (n=35) and KRd (n=21), none was preferred in high-risk pts. Conclusion This real-world study reveals quite heterogeneous treatment choices in 1st and 2nd line pts with high-risk cytogenetic features with no large consensus, especially between EU5 and the US. Some trends can be identified between different pts subsets: quadruplets with D-VRd and D-VTd in EU5 and D-VRd in the US are preferred as induction treatment prior to SCT. VRd is regularly used in 1st line SCT ineligible pts in the EU5, particularly in case of del17p. Carfilzomib-based regimens are more common in 2nd line pts in both EU5 and US, especially DKd, KRd and Kd. Those are in line with the main international guidelines and expert recommendations for high-risk pts.

Adapting a Clinical Practice Guideline for Management of Patients with Knee and Hip Osteoarthritis by Hong Kong Physiotherapists.

Knee and hip osteoarthritis are common disabling conditions globally. Although numerous international clinical practice guidelines exist to guide physiotherapy management, not all recommendations issued from these guidelines can be translated to other contexts without considering the cultural acceptability and clinical implementability of targeted countries. Because the ADAPTE framework provides a robust methodology to adapt guidelines to the local context, this study used its methodology to adapt high-quality guideline recommendations to promote optimal physiotherapy care for knee and hip osteoarthritis in Hong Kong. The ADAPTE framework was used and modified to complete the adaptation process. International clinical practice guidelines were identified from eight guideline clearinghouses and six electronic databases. Two independent reviewers critically appraised the eligible guidelines using the AGREE II tool. We extracted and tabulated recommendations from high-quality guidelines. A voting-based consensus among interdisciplinary experts was conducted to decide on suitable recommendations for the Hong Kong context and whether there was a need to modify them. Pertinent recommendations were then translated into the traditional Chinese language. Our team members suggested modifying four tools and adding one to explore the patient's feedback on the recommendations, to the ADAPTE framework. The adaptation was performed on three high-quality guidelines. We adapted 28 and 20 recommendations for treating knee and hip osteoarthritis, respectively. We recommend a multimodal treatment for managing knee and hip osteoarthritis. Land- and aquatic-based exercises, patient education, and self-management were strongly recommended for patients with knee osteoarthritis. Land- and aquatic-based exercises were strongly recommended for patients with hip osteoarthritis. This is the first adaptation study in Hong Kong. It provides guidance to local physiotherapists on managing patients with knee and hip osteoarthritis. Future studies should test the effectiveness of implementing this adapted guideline to improve local physiotherapy care in Hong Kong.

Practice guidelines for cardiovascular disease: how is depression addressed?

Abstract Introduction Multimorbidity is associated with increased mortality, decreased quality of life, and increased use of healthcare services and complicates medical decision-making. Depression is more prevalent among patients with CVD than in the general population, with a direct impact on cardiovascular outcomes and management. Clinical practice guidelines (CPGs) aim to provide the best available advice for improving patient care and outcomes. Question: Do CPGs on CVD provide any practical guidance on depression screening and management? Methods National and international CPGs on CVD prevention and management published between 2012 and 2023. English language only. Databases: MEDLINE n=2432. EMBASE n=327; G.I.N. n=57; Guideline Central: n=97; Uptodate n=26; Society homepages (e.g. NICE, SIGN) n=7. Selection criteria: general management guidelines for adult patients diagnosed with a CVD, as well as disease-specific CPGs (e.g. heart failure (HF), coronary artery disease, peripheral arterial disease (PAD), ischaemic disease, stroke or hypertension (HT)) providing patient-management guidance. Eligible guidelines: evaluated for any mention of depression, with a focus on: 1) recommendations regarding depression screening and treatment; 2) drug-drug or drug-disease interactions associated with depression. Results 43 CVD CPGs provide comprehensive management advice: 7 from CVD in general and 36 from specific disease in CVD (11 from HT, 7 from ischemic heart disease, 7 from HF, 5 from dyslipidemia, 3 from stroke, and 3 from PAD). 26 CVD CPGs mention depression as a CV comorbidity at least once: 22 in specific disease CPG and 4 in general CVD CPGs. 15 CVD CPGs advise to screen for depression: 4 from CVD in general and 11 from specific disease in CVD (4 from ischemic heart disease, 3 from HF, 2 from HT, 1 from PAD, and 1 from stroke). 8 CVD clinical practice guidelines provide advice on management of depression: 3 from CVD in general and 5 from specific disease (2 from HT, 2 from ischemic heart disease and 1 from HF). 4 CVD clinical practice guidelines advise on drug-drug or drug-disease interactions. When provided, the level and quality of guidance for treating physicians on how to screen and manage depression remains very low. Conclusion Management of CVD in the specific clinical setting of depression remains poorly addressed, despite it being documented that factors associated with poor adherence to CVD treatment include depression. Future directions: The psychosocial needs of patients with CVD should be systematically assessed and addressed in an evidence-based manner. There is a need for clear practical guidance on the frequency at which a patient’s mental health should be reassessed. Patient panels can help provide practical information toward addressing depression in the development of guidelines.The AIDS CPG address depression in detail and could serve as a model for future CVD CPGs.

Interventions to improve physical function for children and young people with cerebral palsy: International clinical practice guideline.

https://onlinelibrary.wiley.com/doi/10.1111/dmcn.15055