International Evidence-based Guidelines Research Articles

Pharmacological Management of Osteoarthritis With a Focus on Symptomatic Slow-Acting Drugs: Recommendations From Leading Russian Experts.

This article describes an updated stepwise algorithm for the pharmacological management of osteoarthritis (OA) to establish a treatment method for patients with OA. In step 1, background maintenance therapy includes symptomatic slow-acting drugs for OA, especially prescription crystalline glucosamine sulfate product, for which the high-quality evidence base of efficacy is unequivocal, or prescription chondroitin sulfate. Oral nonsteroidal anti-inflammatory drugs (NSAIDs) or paracetamol only as rescue analgesia is given on top of the background therapy. Step 2: For patients with persistent OA symptoms, the use of oral NSAIDs is mandatory for maintaining supportive therapy with symptomatic slow-acting drugs for OA. It is recommended to properly stratify patients and carefully select oral NSAID therapy to maximize the benefit-to-risk ratio. Intra-articular hyaluronic acid and intra-articular corticosteroids are recommended as well in step 2 of the algorithm, especially for patients who do not respond to the previous therapies. Step 3: Duloxetine is considered along with the previous procedures, especially in patients with pain from central sensitization. Step 4: Total joint replacement is recommended for patients with severe symptoms and poor quality of life. The current guidelines and literature review provide evidence-based recommendations supported by clinical experience on how to organize the treatment process in patients with knee OA applicable in the Russian clinical practice. International evidence-based guidelines lack consensus on different treatments, including the use of prescription crystalline glucosamine sulfate, NSAIDs, and intra-articular hyaluronic acid. The content of this article needs a further discussion about the clinical evidence and harmonization of recommendations for knee OA management.

Drug Therapy Problems and Predictors Among Patients Admitted to Medical Wards of Dilla University Referral Hospital, South Ethiopia: A Case of Antimicrobials.

PurposeTo assess antimicrobial use-related problems and associated factors among patients admitted to medical wards of Dilla University Referral Hospital.Patients and MethodsA hospital-based prospective observational study design was employed to assess the antimicrobial use-related problems among adult patients admitted to Dilla University Referral Hospital from 5 March to 4 September 2018. The antimicrobial therapy was reviewed to assure compliance with the recommendations of the national guidelines or evidence-based international clinical guidelines and drug therapy problem was identified. The logistic regression model was fit to determine the association between the different factors and the occurrence of drug therapy problems. Odds ratio was used to show a comparison of factors contributing to drug therapy problems. Statistical significance was considered at p-value <0.05.ResultsIn this follow-up to 229 participants, the prevalence of antimicrobial therapy-related problem was 70.74%. “Noncompliance to therapy” was the most frequent DTP experienced by 68 (29.69%) of the patients followed by “needs additional drug therapy” seen among 31 (13.54%) patients. “Adverse drug reaction” was the least and experienced by 7 (3.06%) patients. Others include: dosage too low among 22 (9.61%), dose too high among 17 (8.30%), unnecessarily prescribed antimicrobials among 17 (7.42%) and ineffective antimicrobials among 8 (3.49%) patients. Compared with those who used less than four drugs, the use of four to six (AOR: 4.024) and seven and above (AOR: 13.516) drugs were determinants for antimicrobial use problems. Additionally, infectious cases not addressed by the national guideline (AOR: 3.328) and the unavailability of appropriate lab values results within 48 hours of hospital admission (AOR: 1.285) were determinants for antimicrobial use problems.ConclusionAntimicrobial use problem was prevalent with 0.94-problems-per-patient. Polypharmacy, coverage of national guidelines and availing laboratory values within 48 hours of hospital admission were independent determinants of antimicrobial use problems.

Clinical Approach to Non-cystic fibrosis Bronchiectasis Based on Recent Clinical Guideline

Non-cystic fibrosis bronchiectasis is a common respiratory disease that is frequently encountered in daily practice. However, it has been regarded as an orphan lung disease and had been often neglected by the physicians. Fortunately, recent studies have unveiled many important clinical aspects of bronchiectasis. Accordingly, international evidence-based practice guideline such as the European Respiratory Society guideline and the British Thoracic Society (BTS) guideline have been published recently. However, as there is no domestic evidence-based guideline, we introduce clinical approaches to diagnose bronchiectasis and discuss important aspects of bronchiectasis based on most recently published the BTS guideline. In addition, we cover the treatment of bronchiectasis based on the BTS guideline. We hope newly assembled a Korean bronchiectasis study group, name the Korean Multicenter Bronchiectasis Audit and Research Collaboration (KMBARC) would contribute to publishing Korean bronchiectasis guideline, soon.

Evidence summaries and recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome: Lifestyle management.

Lifestyle is fundamental in chronic disease prevention and management, and it has been recommended as a first-line treatment in the Australian polycystic ovary syndrome (PCOS) guideline 2011. The first international evidence-based guideline on PCOS was developed in 2018, which expanded the scope and evidence in the Australian guideline. This paper summarizes the lifestyle recommendations and evidence summaries from the guideline. International multidisciplinary guideline development groups delivered the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2018. The process followed the Appraisal of Guidelines for Research and Evaluation II and The Grading of Recommendations, Assessment, Development and Evaluation framework. Extensive communication and meetings addressed six prioritized clinical questions through five reviews. Evidence-based recommendations were formulated before consensus voting within the panel. Evidence shows the benefits of multicomponent lifestyle intervention, efficacy of exercise and weight gain prevention with no specific diet recommended. Lifestyle management is the first-line management in the intervention hierarchy in PCOS. Multicomponent lifestyle intervention including diet, exercise and behavioural strategies is central to PCOS management with a focus on weight and healthy lifestyle behaviours. The translation programme optimizes reach and dissemination for health professionals and consumers.

OR31-02 Diagnostic Criteria for Polycystic Ovary Syndrome in Adolescents: Impact on Prevalence and Longitudinal Body Mass Index Trajectories

Background: Polycystic ovary syndrome (PCOS) is characterised by oligo-anovulation (OA), hyperandrogenism (HA) and polycystic ovary morphology (PCO). While the Rotterdam criteria (defined as 2 out of 3 features) are the most widely used criteria in adults, controversy remains for the diagnostic criteria in adolescents as many PCOS features overlap with normal pubertal physiological changes. The 2018 international evidence-based PCOS guideline recommends modified Rotterdam criteria (OA and HA) in adolescents based on expert consensus. We aimed to 1) compare the prevalence of PCOS using original and modified Rotterdam criteria in an unselected adolescent cohort and 2) explore the association between diagnostic phenotypes and long-term body mass index (BMI) trajectories. Methods: 227 adolescent females of the Western Australian Pregnancy Cohort (Raine) Study undertook detailed PCOS assessment at the mean age of 15.3 years (mean age of menarche 12.4 years). Detailed anthropometric measurements were collected from birth until age 22 years. T-test was used for group BMI comparisons and longitudinal BMI was analysed using Generalised Estimating Equations with PCOS by time and PCOS phenotypes by time as interaction terms. Results: PCOS was diagnosed in 66 (29.1%) participants using original Rotterdam criteria versus 37 (16.3%) participants using modified Rotterdam criteria. Using modified Rotterdam criteria, participants with PCOS had higher mean group BMI than participants without PCOS from age 5 years onwards. Significant interaction was detected between PCOS and time (p<0.001) on longitudinal BMI gain where higher BMI gain was observed in participants with PCOS from age 14 years onwards. Only the modified criteria phenotype was significantly associated wth long-term BMI gain whereas other PCOS phenotypes had similar BMI trajectories as participants without PCOS (p<0.001). Conclusions: Our findings validate the PCOS guideline recommendation as modified Rotterdam criteria reduce over-diagnosis of PCOS in adolescents and accurately identify the phenotype at risk of long-term weight gain. The BMI trajectories of females with and without PCOS diverge from early childhood suggesting that metabolic dysfunction in PCOS commences early in the pre-pubertal period. Disclosures: Nothing to disclose. Funding: PCOS CRE scholarship and Research Training Program Scholarship awarded to CT; NHMRC Medical Research Future fund awarded to HT; National Heart Foundation Future Leader Fellowship awarded to LM; NHMRC early career fellowship awarded to AJ.

OR31-01 A Randomized Controlled Trial of a Lifestyle Intervention with Longitudinal Follow up on Ovarian Dysmorphology, Hyperandrogenism, and Menstrual Irregularity in Women with Polycystic Ovary Syndrome

The recent International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (PCOS) recommended healthy lifestyle interventions (dietary, exercise, behavioral modification, or combined) as the first-line therapy to mediate favorable metabolic outcomes in PCOS. However, the relationship between lifestyle modifications and reproductive health in PCOS is less clear. Specifically, a favorable dietary composition to facilitate reproductive changes in women with PCOS remains unknown. Further, the longitudinal impacts of lifestyle change programs in women with PCOS is poorly elucidated. We hypothesized that a low glycemic index pulse-based diet containing lentils, beans, split peas, and chickpeas would be more effective than the Therapeutic Lifestyle Changes (TLC) diet at improving insulin sensitivity without an energy-restricted protocol and would improve reproductive health outcomes in women with PCOS after a 16-week intervention. Our objective was to compare the effects of a nutritionally balanced pulse-based diet with the TLC diet on ultrasonographic markers of ovarian morphology, hyperandrogenism, and menstrual irregularity. Women (n=30) randomized to the pulse-based and TLC (n=31) groups completed a 16-week intervention. All women participated in aerobic exercise (minimum 5 days/week; 45 minutes/day) and received health counseling (monthly) about PCOS and the benefits of lifestyle modification. Additionally, we evaluated the effects of the intervention on the reproductive outcomes by longitudinal follow-up of all participants. Follicle numbers per ovary (FNPO, 2-9 mm), ovarian volume (OV), free androgen index (FAI), intermenstrual intervals, and insulin sensitivity (Matsuda index and homeostasis model assessment of insulin resistance [HOMA-IR] were evaluated at baseline, 16-week post-intervention, and 6- and 12-month post-intervention follow up visits. Follicle numbers per ovary (mean change ± SD, -10 ± 15), OV (-2.7 ± 4.8 mL), FAI (-3 ± 2), intermenstrual interval (-13 ± 47 days), and body mass index (BMI, -1.6 ± 4.2 kg/m2) decreased, and Matsuda index (1.1 ± 3.1) increased over time in both groups (All: P ≤ 0.01), without group-by-time interactions (All: P ≥ 0.27). Groups maintained reduced OV, FNPO, FAI, and menstrual cycles 6 months post-intervention, despite a propensity for weight regain as evidenced by increased BMI (1.0 ± 4.8 kg/m2; P < 0.01). Decreased FNPO, FAI, and HOMA-IR at 16-week tended to revert to baseline levels 12 months post-intervention in both groups (All: P ≤ 0.05). Both interventions improved ovarian dysmorphology, hyperandrogenism, and menstrual irregularity in women with PCOS. Our observations elucidate the importance of longitudinal surveillance for sustainable adherence to newly adopted healthy lifestyle behaviors and reproductive health in PCOS (ClinicalTrials.gov identifier, NCT01288638).

The French national protocol for Kennedy\u2019s disease (SBMA): consensus diagnostic and management recommendations

BackgroundKennedy’s disease (KD), also known as spinal and bulbar muscular atrophy (SBMA), is a rare, adult-onset, X-linked recessive neuromuscular disease caused by CAG expansions in exon 1 of the androgen receptor gene (AR). The objective of the French national diagnostic and management protocol is to provide evidence-based best practice recommendations and outline an optimised care pathway for patients with KD, based on a systematic literature review and consensus multidisciplinary observations.ResultsThe initial evaluation, confirmation of the diagnosis, and management should ideally take place in a tertiary referral centre for motor neuron diseases, and involve an experienced multidisciplinary team of neurologists, endocrinologists, cardiologists and allied healthcare professionals. The diagnosis should be suspected in an adult male presenting with slowly progressive lower motor neuron symptoms, typically affecting the lower limbs at onset. Bulbar involvement (dysarthria and dysphagia) is often a later manifestation of the disease. Gynecomastia is not a constant feature, but is suggestive of a suspected diagnosis, which is further supported by electromyography showing diffuse motor neuron involvement often with asymptomatic sensory changes. A suspected diagnosis is confirmed by genetic testing. The multidisciplinary assessment should ascertain extra-neurological involvement such as cardiac repolarisation abnormalities (Brugada syndrome), signs of androgen resistance, genitourinary abnormalities, endocrine and metabolic changes (glucose intolerance, hyperlipidemia). In the absence of effective disease modifying therapies, the mainstay of management is symptomatic support using rehabilitation strategies (physiotherapy and speech therapy). Nutritional evaluation by an expert dietician is essential, and enteral nutrition (gastrostomy) may be required. Respiratory management centres on the detection and treatment of bronchial obstructions, as well as screening for aspiration pneumonia (chest physiotherapy, drainage, positioning, breath stacking, mechanical insufflation-exsufflation, cough assist machnie, antibiotics). Non-invasive mechanical ventilation is seldom needed. Symptomatic pharmaceutical therapy includes pain management, endocrine and metabolic interventions. There is no evidence for androgen substitution therapy.ConclusionThe French national Kennedy’s disease protocol provides management recommendations for patients with KD. In a low-incidence condition, sharing and integrating regional expertise, multidisciplinary experience and defining consensus best-practice recommendations is particularly important. Well-coordinated collaborative efforts will ultimately pave the way to the development of evidence-based international guidelines.

Adolescent polycystic ovary syndrome according to the international evidence-based guideline

BackgroundDiagnosing polycystic ovary syndrome (PCOS) during adolescence is challenging because features of normal pubertal development overlap with adult diagnostic criteria. The international evidence-based PCOS Guideline aimed to promote accurate and timely diagnosis, to optimise consistent care, and to improve health outcomes for adolescents and women with PCOS.MethodsInternational healthcare professionals, evidence synthesis teams and consumers informed the priorities, reviewed published data and synthesised the recommendations for the Guideline. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied to appraise the evidence quality and the feasibility, acceptability, cost, implementation and strength of the recommendations.ResultsThis paper focuses on the specific adolescent PCOS Guideline recommendations. Specific criteria to improve diagnostic accuracy and avoid over diagnosis include: (1) irregular menstrual cycles defined according to years post-menarche; > 90 days for any one cycle (> 1 year post-menarche), cycles< 21 or > 45 days (> 1 to < 3 years post-menarche); cycles < 21 or > 35 days (> 3 years post-menarche) and primary amenorrhea by age 15 or > 3 years post-thelarche. Irregular menstrual cycles (< 1 year post-menarche) represent normal pubertal transition. (2) Hyperandrogenism defined as hirsutism, severe acne and/or biochemical hyperandrogenaemia confirmed using validated high-quality assays. (3) Pelvic ultrasound not recommended for diagnosis of PCOS within 8 years post menarche. (4) Anti-Müllerian hormone levels not recommended for PCOS diagnosis; and (5) exclusion of other disorders that mimic PCOS. For adolescents who have features of PCOS but do not meet diagnostic criteria an ‘at risk’ label can be considered with appropriate symptomatic treatment and regular re-evaluations. Menstrual cycle re-evaluation can occur over 3 years post menarche and where only menstrual irregularity or hyperandrogenism are present initially, evaluation with ultrasound can occur after 8 years post menarche. Screening for anxiety and depression is required and assessment of eating disorders warrants consideration. Available data endorse the benefits of healthy lifestyle interventions to prevent excess weight gain and should be recommended. For symptom management, the combined oral contraceptive pill and/or metformin may be beneficial.ConclusionsExtensive international engagement accompanied by rigorous processes honed both diagnostic criteria and treatment recommendations for PCOS during adolescence.

Receiving care according to national heart failure guidelines is associated with lower total costs: an observational study in Region Halland, Sweden.

Patients with heart failure (HF) have high costs, morbidity, and mortality, but it is not known if appropriate pharmacotherapy (AP), defined as compliance with international evidence-based guidelines, is associated with improved costs and outcomes. The purpose of this study was to evaluate HF patients' health care utilization, cost and outcomes in Region Halland (RH), Sweden, and if AP was associated with lower costs. A total of 5987 residents of RH in 2016 carried HF diagnoses. Costs were assigned to all health care utilization (inpatient, outpatient, emergency department, primary health care, and medications) using a Patient Encounter Costing methodology. Care of HF patients cost €58.6 M, (€9790/patient) representing 8.7% of RH's total visit expenses and 14.9% of inpatient care (IPC) expenses. Inpatient care represented 57.2% of this expenditure, totalling €33.5 M (€5601/patient). Receiving AP was associated with significantly lower costs, by €1130 per patient (P < 0.001, 95% confidence interval 574-1687). Comorbidities such as renal failure, diabetes, chronic obstructive pulmonary disease, and cancer were significantly associated with higher costs. Heart failure patients are heavy users of health care, particularly IPC. Receiving AP is associated with lower costs even adjusting for comorbidities, although causality cannot be proven from an observational study. There may be an opportunity to decrease overall costs and improve outcomes by improving prescribing patterns and associated high-quality care.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BackgroundPoint-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.MethodsCreation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.ResultsPanellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).ConclusionsEvidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Diag nostics of gonorrhoea in Ukraine following World Health Organization recommendations

Objective — to evaluate the compliance of gonorrhoea diagnostics in regional skin and venereological dispensaries (RSVD) in Ukraine during 2013—2014 to World Health Organization (WHO) laboratory recommendations and identify areas for its improvement. Materials and methods. The study analyzed statistics data regarding the number of performed laboratory tests and their positive results for the detection of gonococci, the collection of biological samples and the use of laboratory methods for N. gonorrhoeae identification obtained from 14 RSVD of Ukraine by questionnaire. Results and discussion. Dispensary laboratories performed microscopy, culture and point-of-care-tests in 100, 85.7 and 7.1 % of patients, respectively. Gonococci were found in 2.3 % of the patients, equally by the results of microscopy (1740/76 348) and by culture (1322/56 273). Dispensary laboratories did not perform nucleic acid amplification tests. Sampling of biological material from three anatomical sites (urogenital, pharyngeal and rectal specimens) in heterosexual patients with symptoms of sexually transmitted infection was performed by 25 % of respondents, from two sites (urogenital and pharyngeal) — by 41.7 %, and from one site (urogenital sample) — by 33.3 % of dispensaries. External quality control of laboratory tests for the detection of N. gonorrhoeae was performed by 50 % of the respondents. Non-selective nutrient media for isolation of N. gonorrhoeae was used by 16.7 % of dispensaries, and prepared nutrient media in test tubes instead of the recommended Petri dishes, were used in 58.3 % of dispensaries. The vast majority of respondents (78.6 %) had an experience of determining gonococcal sensitivity to antibiotics. Two institutions (14.3 %) participated in an international pilot project to determine the antibiotic resistance of gonococci. Conclusions. Diagnostics of gonococcal infection in Ukraine is not optimal and needs improvement by using quality-tested bacteriological cultures and point-of-care-tests, implementation of nucleic acid amplification tests, monitoring of gonococcal sensitivity to antibiotics, collection of extragenital biological samples. Adherence to evidence-based international guidelines and adapted national guidelines for the diagnostics of gonorrhoea is an essential factor of the controlling of gonococcal infection.

Antimicrobial prophylaxis for adult surgical patients in a Pakistani teaching hospital

Summary Objective To evaluate the compliance rate of Surgical antimicrobial prophylaxis (SAP) practices with guidelines among adult surgical patients. Method A cross-sectionalobservational study was conducted in a teaching hospital in Pakistan. A total of 235 surgical procedures were investigated during two-month study period through convenient sampling technique. Important data was collected from patients’ prescription records through specialized data collection form. The observed practices were compared with international evidence-based guidelines. Results Most of the surgical procedures belonged to general surgical wards (60%; n = 141). Clean surgical procedures were more important (51%; n = 120) when compared to clean-contaminated surgeries (49%; n = 115). The selection of antimicrobial was correct in 32% (n = 76), timing in 39.5% (n = 93), route and dose in 100% (n = 235) of the surgical cases. The selection and timing of SAP administration were more adhered with the guidelines in the urological ward as compared to orthopaedic and general surgical wards (P

Operative vaginal delivery: a review of four national guidelines.

There is a broad range in the rates of operative vaginal deliveries (OVD) worldwide, which reflects the variety of local practice patterns, the number of trained clinicians and the lack of international evidence-based guidelines. The aim of this study was to review and compare the recommendations from published guidelines on OVD. Thus, a descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the American College of Obstetricians and Gynecologists (ACOG) on instrumental vaginal birth was conducted. All the guidelines point out that the use of any instrument should be based on the clinical circumstances and the experience of the operator. The indications, the contraindications, the prerequisites and the classification for OVD are overall very similar in the reviewed guidelines. Further, they all agree that episiotomy should not be performed routinely. The RCOG, the RANZCOG and the SOGC describe some interventions which may promote spontaneous vaginal birth and therefore reduce the need for OVD. They also highlight the importance of adequate postnatal care and counseling. There is no consensus on the actual technique that should be used, including the type of forceps or vacuum cup, the force and duration of traction or the number of detachments allowed. Hence, there is need for international practice protocols, so as to encourage the clinicians to use OVD when indicated, minimize the complications and reduce rates of cesarean delivery.

Standards for the development and methodology of the 2019 International Working Group on the Diabetic Foot guidelines.

Diabetic foot disease is a source of major patient suffering and societal costs. Investing in evidence-based international guidelines on diabetic foot disease is likely among the most cost-effective forms of health care expenditure, provided the guidelines are outcome focused, evidence based, and properly implemented. The International Working Group on the Diabetic Foot (IWGDF) has published and updated international guidelines since 1999. The 2019 updates are based on formulating relevant clinical questions and outcomes, rigorous systematic reviews of the literature, and recommendations that are specific, and unambiguous along with their transparent rationale, all using the Grading of Recommendations Assessment Development and Evaluation (GRADE) framework. We herein describe the development of the 2019 IWGDF guidelines on the prevention and management of diabetic foot disease, which consists of six chapters, each prepared by a separate working group of international experts. These documents provide guidelines related to diabetic foot disease on prevention; offloading; peripheral artery disease; infection; wound healing interventions; and classification of diabetic foot ulcers. Based on these six chapters, the IWGDF Editorial Board also produced a set of practical guidelines. Each guideline underwent extensive review by the members of the IWGDF Editorial Board as well as independent international experts in each field. We believe that adoption and implementation of the 2019 IWGDF guidelines by health care providers, public health agencies, and policymakers will result in improved prevention and management of diabetic foot disease and a subsequent worldwide reduction in the patient and societal burden this disease causes.

Deprescribing in older people.

Polypharmacy and multimorbidity are both currently rising. The number of medicines taken is the single biggest predictor of adverse drug events. Deprescribing is an approach to managing polypharmacy and reducing adverse outcomes. Multiple international evidence-based guidelines are emerging to promote discontinuation of high-risk medications, and use of alternative medical and non-pharmacological management. This review outlines the evidence base behind deprescribing, and suggests some pragmatic approaches to decision making around medication review.

Management of non-specific low back pain in primary care – A systematic overview of recommendations from international evidence-based guidelines

Systematic identification, characterization and analysis of recommendations concerning the diagnosis and treatment of non-specific low back pain (LBP) in primary care provided in international evidence-based guidelines from high-income countries. LBP is one of the most common reasons for consulting a primary care physician and its prevalence is higher in high-income than in middle- or low-income countries. The majority of LBP is non-specific and treatment recommendations are not often based on high-quality and patient-oriented evidence. We systematically searched PubMed and major guideline databases from 2013 to 2020. Two independent reviewers performed literature selection and the quality assessment of included guidelines using the AGREE II tool. We extracted all relevant recommendations including the corresponding Grade of Recommendation. We grouped all included recommendations by topic and compared them to each other. This overview includes 10 current guidelines and overall 549 relevant recommendations. Recommendations covered aspects of assessment and diagnosis (15%), non-pharmacological interventions (46%), pharmacological interventions (26%), invasive treatments (8%) and multimodal pain management (5%). In total, 30% of all recommendations were strong and 57% weak or very weak. The proportion of recommendations for and against an intervention was 45% and 38%, respectively. The recommendations from the different guidelines were largely in good agreement. We identify only a small number of contradictory recommendations, mostly dealing with very specific interventions. In conclusion, current evidence-based guidelines published in high-income countries provide recommendations for all major aspects of the management of people with LBP in primary care. Recommendations from different guidelines were largely consistent. More than 50% of these recommendations were weak or very weak and a high proportion of recommendation advised against an intervention.

Management of hepatic encephalopathy in Germany: a survey among physicians.

Hepatic encephalopathy (HE) is a severe complication of liver cirrhosis with impairment of quality of life and prognosis. Management patterns among physicians have not been investigated yet. A questionnaire containing 17 questions was sent out to 1468 gastroenterologists and 120 general practitioners (GPs). It included questions regarding diagnostic, therapeutic, and management strategies used in patients with overt HE (OHE) and covert HE (CHE). The response rate was 12 % (n = 172) for gastroenterologists and 45 % (n = 54) for GPs. Of gastroenterologists, 26.7 % examine patients with an initial diagnosis of liver cirrhosis regarding HE. Gastroenterologists favored a combination of different testing strategies (27.9 %) and clinical examination (23.0 %), while the biggest part of the GPs use clinical examination (55.3 %); 63.7 % of gastroenterologists and 28.3 % of GPs give correct nutritional advices to patients with HE. Treatment strategies for acute bouts of OHE and secondary prophylaxis varied widely in both groups. Preferred medication was lactulose followed by rifaximin or a combination therapy. More than half of the GPs (53.7 %) were not familiar with minimal HE (MHE). About one-third of both groups never tried to diagnose MHE. Our data strongly indicate that management of HE is very heterogeneous among gastroenterologists as well as selected GPs working in Germany and not driven by evidence-based international guidelines. Thus, the national guideline is more than welcome.

Guidelines for Chinese medicine rehabilitation of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common, chronic, frequently occurring, and difficult disease of the respiratory system and is a huge disease burden. Pulmonary rehabilitation is an important part of clinical treatment. Chinese medicine lung rehabilitation (CMLR), which is based on Chinese medicine theory and practice, is a comprehensive rehabilitation measure that can prevent and treat pulmonary diseases and preserve physical and mental functions. Its aim is to promote the return of patients to society as soon as possible. To better guide the clinical practice of COPD rehabilitation, the Specialty Committee of Pulmonary Rehabilitation of World Federation of Chinese Medicine Societies established a panel for formulating guidelines, systematically retrieved domestic and foreign literature, performed systematic evaluation after expert consultation and on-site discussion, and finally, formed the guidelines in accordance with the development standard of international evidence-based guidelines. The guideline has seven parts, which are the preface, introduction, scope, normative references, terms and definitions, types of disease syndromes, diseases assessment, CMLR techniques, and annex. The techniques of CMLR include 11 techniques in seven species, such as Simplified Taijiquan, Baduanjin, and Liuzijue. The guideline defines the technical points (time, frequency, course, etc.), optimal applicable population, use of drugs, common acupoints, operation methods, and so on for each technique. The release of the guidelines is helpful to improve the rehabilitation technique standardization and to improve the curative effect and level of rehabilitation.

A review of therapeutic options for managing the metabolic aspects of polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women of reproductive age. Metabolic sequelae associated with PCOS range from insulin resistance to type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). Insulin resistance plays a significant role in the pathophysiology of PCOS and it is a reliable marker for cardiometabolic risk. Although insulin sensitising agents such as metformin have been traditionally used for managing metabolic aspects of PCOS, their efficacy is low in terms of weight reduction and cardiovascular risk reduction compared with newer agents such as incretin mimetics and SGLT2 inhibitors. With current pharmaceutical advances, potential therapeutic options have increased, giving patients and clinicians more choices. Incretin mimetics are a promising therapy with a unique metabolic target that could be used widely in the management of PCOS. Likewise, bariatric procedures have become less invasive and result in effective weight loss and the reversal of metabolic morbidities in some patients. Therefore, surgical treatment targeting weight loss becomes increasingly common in the management of obese women with PCOS. Newer emerging therapies, including twincretins, triple GLP-1 agonists, glucagon receptor antagonists and imeglemin, are promising therapeutic options for treating T2DM. Given the similarity of metabolic and pathological features between PCOS and T2DM and the variety of therapeutic options, there is the potential to widen our strategy for treating metabolic disorders in PCOS in parallel with current therapeutic advances. The review was conducted in line with the recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018.

New Approach to Chronic Cough: An Introductory Guide Based on Recent Clinical Practice Guidelines

The cough reflex is a vital protective mechanism for the lower airways against aspiration, but when dysregulated, it becomes a clinical problem. Indeed, chronic cough is an important clinical issue as it is common in the general population and causes considerable morbidity. Anatomic diagnostic protocols were the first breakthrough in the management of patients with chronic cough; however, as systematic approaches are not always successful, a new paradigm of cough hypersensitivity syndrome has been proposed. The introduction of this paradigm has provided new opportunities for managing chronic cough, including development of new cough assessment tools and effective cough control therapies. However, it also warranted re-appraisal of existing clinical evidence and refinement of our clinical pathways. Against this background, international and domestic evidence-based practice guidelines based on a strict methodology have been published recently. In this review, we introduce clinical approaches based on the concept of cough hypersensitivity syndrome and discuss key aspects of recently published guidelines for chronic cough in adults. Keywords: Cough; Guideline 중심 단어: 기침; 가이드라인