National Evidence-based Guidelines Research Articles

Skandinaviske retningslinjer for behandling av psykisk lidelse hos barn og unge: En kvalitetsvurdering

Children and young people with untreated mental health disorders can develop chronic disorders and severe somatic diseases later in life. The right treatment at the right time is therefore important to promote good mental health. Healthcare personnel are required to follow national guidelines, and high-quality guidelines are thus important for patient safety. We wanted to assess the quality of Norwegian national guidelines for the treatment of mental disorders in children and young people and compare these with corresponding guidelines in Sweden and Denmark. We conducted manual searches in the relevant national health authorities’ websites and selected five Norwegian guidelines (treatment of ADHD, bipolar disorders, psychosis, suicide and eating disorders), three Danish guidelines (ADHD, anorexia and bulimia) and one Swedish guideline (ADHD). For the purpose of quality assessment, we used an internationally recognised checklist (AGREE II), on which Norwegian guidelines must be developed in accordance with the Norwegian Directorate of Health’s own guide for developing guidelines. The checklist consists of 23 items divided into six domains: scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, and editorial independence. We found that the overall quality of the Danish and Swedish guidelines was very high and met most of the 23 criteria organised within six domains. The Norwegian guidelines met the criteria for scope and purpose and stakeholder involvement, but had major shortcomings in terms of rigour of development, clarity of presentation, applicability, and transparency of editorial independence. Keywords: evidence-based practice, national guidelines, children and adolescents, mental disorders

Exploring implementation of intrapartum trial evidence: a qualitative study with clinicians and clinical academics

BackgroundImplementing research evidence into clinical practice is challenging. This study aim was to explore implementation of two intrapartum trials with compelling findings: BUMPES (position in second stage of labour in nulliparous women with epidural), and RESPITE (remifentanil intravenous patient-controlled analgesia). MethodsA qualitative interview study set in UK National Health Service Trusts and Universities. Purposively sampled investigators from RESPITE and BUMPES trials and clinicians providing intrapartum care: midwives, anaesthetists, and obstetricians, were recruited using existing networks and snowball sampling. Semi-structured virtual interviews were conducted. Thematic analysis was underpinned by Capability Opportunity Motivation Behaviour Change Framework.ResultsTwenty-nine interview participants across 19 maternity units: 11 clinical academics, 10 midwives, 4 obstetricians, 4 anaesthetists. Most (25/29) were aware of one or both trials. BUMPES had been implemented in 4/19 units (one original trial site) and RESPITE in 3/19 units (two trial sites). Access to sufficient resources, training, exposure to interventions, support from leaders, and post-trial dissemination and implementation activities all facilitated uptake of interventions. Some clinicians were opposed to the intervention or disagreed with trial conclusions. However competing priorities in terms of staff time and a plethora of initiatives in maternity care, emerged as a key barrier to implementation.ConclusionsCompelling trial findings were not implemented widely, and numerous barriers and facilitators were identified. Large-scale improvement programmes and evidence-based national guidelines may mean single trials have limited potential to change practice. There is a need to examine how intervention implementation is prioritised to optimise safety outcomes in the context of workforce restrictions, limited resources and large arrays of competing priorities including statutory requirements, that have increased in maternity care.

Diabetic retinopathy

Diabetic retinopathy (DR) is the most common complication in patients with diabetes, and screening for sight-threatening end-stages is indicated to avoid severe visual loss. Screening of DR is nationally implemented in Denmark according to evidence-based national guidelines, which includes the use of individualised screening intervals. Treatment is indicated for proliferative DR and diabetic macular oedema, and treatment modalities include retinal laser therapy, intravitreal angiostatic therapy, and vitrectomy. In this review, we summarise the current guidelines for screening and treatment of DR in Denmark.

United Arab Emirates Consensus Recommendations for Management of Acne Vulgaris.

Acne in the United Arab Emirates is a common disease that causes burden to patients, has psychosocial impacts, and is associated with physical sequelae such as dyspigmentation and scarring. This guideline, which was developed from an evaluation of existing international and national evidence-based acne guidelines along with live meetings of United Arab Emirates acne experts, is designed to facilitate the management of acne in the UAE health care system. It discusses the evaluation of acne severity, evidence-based guidance on acne treatment, and strategies for the management of this chronic disease. Effective treatment of active lesions and prevention of sequela is likely to improve the health of many United Arab Emirates patients with acne. J Drugs Dermatol. 2024;23(8):653-660.  doi:10.36849/JDD.7748R1.

A survey of the prevalence and patterns of neuropsychological assessment practices across epilepsy surgery centers in India: Toward establishing a national guideline.

Neuropsychology plays an important role in optimizing epilepsy management, but there are no practice guidelines for low- and middle-income countries with emerging services. The National Epilepsy Surgery Support Activity Network (NESSAN), a national working group that supports and optimizes epilepsy surgery programs in India, explored the present status of pre- and post epilepsy surgery neuropsychological assessment practices across India as an initial step in developing national evidence-based test guidelines. An online survey was conducted using two questionnaires, one for neurologists and the second for neuropsychologists and speech-language pathologists working in epilepsy surgery centers. The questions to neurologists covered the setting, description, and nature of the neuropsychology services provided for adults and children as part of the epilepsy surgery program, and their perceptions about the importance and indications for neuropsychological assessment in epilepsy surgery. The questions to neuropsychologists inquired about their qualifications and training, pre- and postsurgical assessment procedures, and domain-specific cognitive tests and scales for mood, quality of life, and language evaluations. Forty-three centers responded, and neuropsychology services were available at three fourth of the centers, but a dedicated full-time neuropsychologist was available in only 16% of centers. Ninety percent of the neurologists considered neuropsychological evaluation an indispensable part of presurgical evaluation. However, only a few of them believed that the results influenced their decision about the extent of resection and ruling against surgery. The survey found considerable heterogeneity in terms of qualifications and training of neuropsychologists, evaluation procedures, test protocols, and normative data that will need to be harmonized to ensure uniform practice across the country. We believe that the results from this survey provide a road map for implementing measures to minimize existing inadequacies and harmonize neuropsychology services in India and as well as in other countries with emerging neuropsychology services. PLAIN LANGUAGE SUMMARY: Neuropsychological assessment is an integral part of the pre- and post epilepsy surgery evaluations. In India, the National Epilepsy Surgery Support Activity Network (NESSAN), a body of multidisciplinary professionals, conducted a survey to examine existing neuropsychology practices. The responses from 43 centers across the country revealed considerable heterogeneity in tests and few trained and qualified neuropsychologists. In low- and middle-income countries (LMIC) with emerging neuropsychology services, there is a need to have uniform test protocols, specialized training, and guidelines for optimizing neuropsychology services across all the epilepsy surgery centers.

Expert consensus statements and summary of proceedings from the International Safety and Quality of Parenteral Nutrition Summit.

The International Safety and Quality of Parenteral Nutrition (PN) Summit consisted of presentations, discussions, and formulation of consensus statements. The purpose here is to briefly summarize the summit and to present the consensus statements. There was a high degree of consensus, with all statements approved by all authors/summit experts. These consensus statements should be regarded not as formal guidelines but rather as best-practice guidance intended to complement national and international nutrition society evidence-based guidelines and position statements. This article also summarizes key discussion topics from the summit, encompassing up-to-date knowledge and practical guidance concerning PN safety and quality in various countries and clinical settings, focusing on adult patients. Clear geographical differences exist between practices in Europe and the United States, and different approaches to improve the safety, quality, and cost-effectiveness of PN vary, particularly with regard to the delivery systems used. Discussion between experts allowed for an exchange of practical experience in optimizing PN use processes, opportunities for standardization, use of electronic systems, potential improvements in PN formulations, better management during PN component shortages, and practical guidance to address patients' needs, particularly during long-term/home PN. The consensus statements are the collective opinion of the panel members and form best-practice guidance. The authors intend that this guidance may help to improve the safety and quality of PN in a variety of settings by bridging the gap between published guideline recommendations and common practical issues.

Current consensus and clinical approach to fragility fractures of the pelvis: an international survey of expert opinion.

Fragility fractures of the pelvis (FFP) in elderly patients are an underappreciated injury with a significant impact on mobility, independency, and mortality of affected patients and is a growing burden for society/health care. Given the lack of clinical practice guidelines for these injuries, the authors postulate there is heterogeneity in the current use of diagnostic modalities, treatment strategies (both operative and nonoperative), and follow-up of patients with FFP. The goal of this study was to assess international variation in the management of FFP. All International Orthopaedic Trauma Association (IOTA) steering committee members were asked to select 15 to 20 experts in the field of pelvic surgery to complete a case-driven international survey. The survey addresses the definition of FFP, use of diagnostic modalities, timing of imaging, mobilization protocols, and indications for surgical management. In total, 143 experts within 16 IOTA societies responded to the survey. Among the experts, 86% have >10 years of experience and 80% works in a referral center for pelvic fractures. However, only 44% of experts reported having an institutional protocol for the management of FFP. More than 89% of experts feel the need for a (inter)national evidence-based guideline. Of all experts, 73% use both radiographs and computed tomography (CT) to diagnose FFP, of which 63% routinely use CT and 35% used CT imaging selectively. Treatment strategies of anterior ring fractures were compared with combined (anterior and posterior ring) fractures. Thirty-seven percent of patients with anterior ring fractures get admitted to the hospital compared with 75% of patients with combined fractures. Experts allow pain-guided mobilization in 72% after anterior ring fracture but propose restricted weight-bearing in case of a combined fracture in 44% of patients. Surgical indications are primarily based on the inability to mobilize during hospital admission (33%) or persistent pain after 2 weeks (25%). Over 92% plan outpatient follow-up independent of the type of fracture or treatment. This study shows that there is a great worldwide heterogeneity in the current use of diagnostic modalities and both nonoperative and surgical management of FFP, emphasizing the need for a consensus meeting or guideline.

Central-line-associated bloodstream infection burden among Dutch neonatal intensive care units

The establishment of an epidemiological overview provides valuable insights needed for the (future) dissemination of infection-prevention initiatives. To describe the nationwide epidemiology of central-line-associated bloodstream infections (CLABSI) among Dutch Neonatal Intensive Care Units (NICUs). Data from 2935 neonates born at <32 weeks' gestation and/or with a birth weight <1500g admitted to all nine Dutch NICUs over a two-year surveillance period (2019-2020) were analysed. Variations in baseline characteristics, CLABSI incidence per 1000 central-line days, pathogen distribution and CLABSI care bundles were evaluated. Multi-variable logistic mixed-modelling was used to identify significant predictors for CLABSI. A total of 1699 (58%) neonates received a central line, in which 160 CLABSI episodes were recorded. Coagulase-negative staphylococci were the most common infecting organisms of all CLABSI episodes (N=100, 63%). An almost six-fold difference in the CLABSI incidence between participating units was found (2.91-16.14 per 1000 line-days). Logistic mixed-modelling revealed longer central line dwell-time (adjusted odds ratio (aOR):1.08, P<0.001), umbilical lines (aOR:1.85, P=0.03) and single rooms (aOR:3.63, P=0.02) to be significant predictors of CLABSI. Variations in bundle elements included intravenous tubing care and antibiotic prophylaxis. CLABSI remains a common problem in preterm infants in The Netherlands, with substantial variation in incidence between centres. Being the largest collection of data on the burden of neonatal CLABSI in The Netherlands, this epidemiological overview provides a solid foundation for the development of a collaborative platform for continuous surveillance, ideally leading to refinement of national evidence-based guidelines. Future efforts should focus on ensuring availability and extraction of routine patient data in aggregated formats.

Development of a multiyear pediatric antibiogram in Georgia identifies antibiotic resistance trends

Background: Antibiograms are used to monitor antibiotic resistance trends and help guide empiric antibiotic treatment. Community pediatricians may not have access to or be comfortable using children’s hospital antibiograms. Creating and disseminating a statewide pediatric antibiogram can help inform antibiotic stewardship efforts.Objective: To develop a pediatric-specific antibiogram for the state of Georgia. Methods: Annual pediatric antibiograms for the 5 children’s hospitals in Georgia from 2014 through 2021 were collected. All sites complied with the Clinical and Laboratory Standards Institute guidelines for antibiomicrobic breakpoints and antibiogram development. Antibiogram data were combined, and the most common bacteria were selected to incorporate into the statewide antibiogram: Staphylococcus aureus, Streptococcus pneumoniae, Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae complex, and Pseudomonas aeruginosa. Antibiogram data were reported as percentage susceptible and total number of isolates. Interhospital susceptibility differences were compared for methicillin-susceptible S. aureus (MSSA), methicillin-resistant S. aureus (MRSA), E. coli, and K. pneumoniae from 2018 through 2021. P &lt; .05 was considered significant. The combined antibiogram data from 2014 through 2021 were used to show antibiotic susceptibility trends over time. Results: The 2021 antibiogram is shown in the Table. For MSSA and MRSA, clindamycin susceptibility was 80% and 85%, respectively. K. pneumoniae susceptibility to amoxicillin-clavulanate was 91%. For E. coli, using urine-specific breakpoints, susceptibility to cefazolin was 89%. A few statistically significant differences in antibiotic susceptibility were detected between hospitals, but most were unlikely to be clinically relevant (all susceptibilities ≥90% or &lt; 80%). A notable exception was trimethoprim-sulfamethoxazole susceptibility for K. pneumoniae, which ranged from 74% to 98% in 2020 and from 74% to 86% in 2021. From 2014 to 2021, the percentage of MRSA decreased from 49% to 34%. Over the 8 years, susceptibility to ceftriaxone for E. coli ranged from 93% to 95% and from 90% to 95% for K. pneumoniae. Susceptibility to meropenem for E. coli and K. pneumoniae ranged from 99% to 100%. Conclusions: Antibiotic susceptibility for pediatric bacterial isolates in Georgia remained stable over time and supported the narrow-spectrum empiric antibiotic treatment recommended in national evidence-based guidelines for skin and soft-tissue infections, community-acquired pneumonia, and uncomplicated urinary tract infections. MRSA rates decreased over time and multidrug-resistant gram-negative bacilli were uncommon and remained stable.Disclosures: None

To Resuscitate or Not to Resuscitate – The Crossroads of Ethical Decision-Making in Resuscitation in the Emergency Department

Emergency physicians (EPs) working in low-resource settings, where patients mainly bear healthcare delivery, face many challenges. Emergency care is patient-centered and ethical challenges are numerous in situations where patient autonomy and beneficence are fragile. This review discusses some of the common bioethical issues in the resuscitation and post-resuscitation phases of treatment, it proposes solutions and emphasizes the necessity for evidence-based ethics and unanimity on ethical standards. After consensus was reached on the article's structure, smaller groups of authors (2-3) wrote narrative reviews of ethical issues like patient autonomy and honesty, beneficence/nonmaleficence and dignity, justice, and specific practices/circumstances like family presence during resuscitation after having discussions with senior EPs. Ethical dilemmas were discussed, and solutions were proposed. The cases related to medical decision-making by proxies, financial constraints in management, and resuscitation in the face of medical futility have been discussed. Solutions proposed include involving hospital ethics committees early on, having financial mechanisms in place beforehand, and allowing some leverage on a case-to-case basis when care is futile. We recommend developing evidence-based national ethical guidelines and incorporating societal and cultural norms with autonomy, beneficence, non-maleficence, honesty, and justice principles.

Case Studies.

British Journal of NursingVol. 32, No. Sup7 Case StudiesCase StudiesGema Munoz-Mozas, Colin Fairhurst, Simon ClareGema Munoz-MozasVascular Access Advanced Nurse Practitioner and Lead Vascular Access Nurse, Royal Marsden NHS Foundation TrustSearch for more papers by this author, Colin FairhurstVascular Access Advanced Clinical Practitioner, University Hospitals Plymouth NHS TrustSearch for more papers by this author, Simon ClareResearch and Practice Development Director, the Association for Safe Aseptic PracticeSearch for more papers by this authorGema Munoz-Mozas; Colin Fairhurst; Simon ClarePublished Online:10 Apr 2023https://doi.org/10.12968/bjon.2023.32.Sup7.S11AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Akhtar N, Lee L. Utilization and complications of central venous access devices in oncology patients. Current Oncology. 2021;281:367-377. https://doi.org/10.3390/curroncol28010039 Crossref, Medline, Google ScholarBD. BD ChloraPrep: summary of product characteristics. 2021. www.bd.com/en-uk/products/infection-prevention/chloraprep-patient-preoperative-skin-preparation/chloraprep-smpc-pil-msds (accessed 2 November 2022) Google ScholarBD. Chloraprep 10.5ml applicator. 2022a. www.bd.com/en-uk/products/infection-prevention/chloraprep-patient-preoperative-skin-preparation/chloraprep-patient-preoperative-skin-preparation-product-line/chloraprep-105-ml-applicator (accessed 26 September 2022) Google ScholarBD. Chloraprep 3ml applicator. 2022b. www.bd.com/en-uk/products/infection-prevention/chloraprep-patient-preoperative-skin-preparation/chloraprep-patient-preoperative-skin-preparation-product-line/chloraprep-3-ml-applicator (accessed 26 September 2022) Google ScholarCenters for Disease Control and Prevention. 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J Hosp Infect. 2014;86(S1):S1-70. https://doi.org/10.1016/S0195-6701(13)60012-2 Crossref, Medline, Google ScholarNational Patient Safety Agency. Promoting safer use of injectable medicines. 2007. https://healthcareea.vctms.co.uk/assets/content/9652/4759/content/injectable.pdf (accessed 3 October 2022) Google ScholarRoyal College of Nursing. Standards for infusion therapy. 4th edn. 2016. www.rcn.org.uk/clinical-topics/Infection-prevention-and-control/Standards-for-infusion-therapy (accessed 26 September 2022) Google ScholarTaxbro K, Chopra V. Appropriate vascular access for patients with cancer. Lancet. 2021;39810298:367-368. https://doi.org/10.1016/S0140-6736(21)00920-X Crossref, Medline, Google Scholar FiguresReferencesRelatedDetails 2 April 2023Volume 32Issue Sup7ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 10 April 2023 Published in print 2 April 2023 Information© MA Healthcare LimitedPDF download

Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection.

Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection.

Kicking the glove habit

British Journal of NursingVol. 32, No. 2 EditorialKicking the glove habitAndrew BartonAndrew Barton(E-mail Address: [email protected])Nurse Consultant, Vascular Access and IV Therapy, Frimley Health NHS Foundation Trust, and Chair, NIVASSearch for more papers by this authorAndrew BartonPublished Online:30 Jan 2023https://doi.org/10.12968/bjon.2023.32.2.S3AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References European Centre for Disease Prevention and Control. Use of gloves in healthcare and non-healthcare settings in the context of the COVID-19 pandemic. 2020. https://tinyurl.com/mwc4suc8 (accessed 16 January 2023) Google ScholarHealth and Safety Executive. The use of gloves. 2022a. https://tinyurl.com/ypwhc5rf (accessed 16 January 2023) Google ScholarHealth and Safety Executive. Safe handling of cytotoxic drugs in the workplace. 2022b. https://tinyurl.com/4s8f374j (accessed 16 January 2023) Google ScholarLoveday HP, Wilson JA, Pratt RJ et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014;86(Suppl 1):S1-70. https://doi.org/10.1016/S0195-6701(13)60012-2 Crossref, Medline, Google ScholarWilson J, Bak A, Loveday HP. Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care. Am J Infect Control. 2017;45(7):779-786. https://doi.org/10.1016/j.ajic.2017.02.019 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetails 26 January 2023Volume 32Issue 2ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 30 January 2023 Published in print 26 January 2023 Information© MA Healthcare LimitedPDF download

An Update on Biosimilars in Rheumatic and Musculoskeletal Disorders

Biosimilars contain a version of the active substance of an approved biologic medicine. They were introduced several years ago; the first biosimilar was approved by the European Medicine Agency in 2006. They are now commonly used to treat several immune-mediated conditions, and large evidence-based national and international guidelines support their use. Biosimilars are licensed for use after going through a comprehensive approval process to demonstrate clinical equivalence to the reference biologic in at least one randomized controlled trial. Once biosimilarity is demonstrated in one indication, this can be used to approve the drug for other indications if the mechanism of action is the same across different indications. Biosimilars do not have any clinically meaningful differences from the originator medicine in terms of quality, safety and efficacy but have a cost-saving benefit. NHS England supports the use of biosimilars, stating that clinicians should use the best-value biological product, including biosimilars. In 2021, the National Institute for Health and Care Excellence lowered the biologic eligibility criteria for rheumatoid arthritis by recommending the use of anti-tumour necrosis factor medications with licensed biosimilars for treating moderate rheumatoid arthritis after conventional disease-modifying anti-rheumatic drugs have failed. This recommendation has enabled more patients to access advanced therapy at an earlier stage of the disease, thus potentially increasing the likelihood of inducing remission and limiting disease progression.

A short-term follow-up study on breastfeeding practices, growth parameters and immunization practices among babies born to COVID-19 positive mothers in a tertiary care hospital.

We aimed to study the impact of the COVID-19 pandemic on exclusive breastfeeding (EBF) rate and routine follow-up practices including immunization. A total of 62 neonates born to COVID-19 positive mothers and an equal number of neonates born to COVID-19 negative mothers were prospectively evaluated for EBF rate and routine neonatal follow-up practices including delay (>7 days) in routine immunization at 3 months follow-up. We further tried to compare the results across two epochs (epoch 1, March-June 2020 and epoch 2, July-November 2020). There was significantly lesser number of babies born to COVID-19 positive mothers on EBF at 3 months of age when compared with the control group (45.1% vs. 96.7%, p = 0.00) as well it was significantly lesser in epoch 1 when compared with epoch 2 (16% vs. 74%, p = 0.00). Further, a significantly higher number of babies born to COVID-19 positive mothers had their routine immunization delayed with no significant difference across the epochs. There was no significant difference in growth parameters between babies born to COVID-19 positive mother when compared with the control group as well as across the epochs. The COVID-19 pandemic has significantly disrupted the EBF rates as well as hampered the routine immunization practices among babies born to COVID-19 positive mothers. Although such practices got improved after the implementation of evidence-based national guidelines, but it is still much below when compared with those born to COVID-19 negative mother.

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

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

Integrated approach for noncommunicable disease management in the Americas.

ABSTRACTAn overview of an integrated approach to improve noncommunicable disease (NCD) management is presented, along with tools on integrating NCD management as part of health system strengthening in the Americas. The study is based on an analysis of Pan American Health Organization/World Health Organization (PAHO/WHO) data and publicly available information on NCD care and capacity, disruptions in NCD services, and guidance on NCD management. Gaps in NCD care are highlighted, in which an estimated 43.0% of men and 28.0% of women with hypertension in Latin America remain undiagnosed; and for those with diabetes, 32.8% in Central and South America are undiagnosed. Yet, only 17/35 countries (49%) in the Americas report having evidence-based national guidelines for NCD management through a primary care approach and only 7/35 countries (20%) report provision of drug therapy, including glycaemic control for eligible persons. To improve NCD management, an integrated approach is needed to coordinate and deliver care across the levels of the health system. This includes increasing primary care capacity and competencies to address multiple chronic conditions, and integration with other complementary programs to avoid missing opportunities for NCD diagnosis and management. An integrated approach to NCD management, and implementation of available tools, should be part of rebuilding health systems after the COVID-19 pandemic.

A National Survey on Perineal Reconstruction Following Standard and Extralevator Abdominoperineal Excision: Current Practices and Trends in the UK.

BackgroundChallenging perineal defects resulting from extralevator (ELAPE) and standard abdominoperineal excision (APE) have given rise to an emerging multidisciplinary approach between colorectal and plastic surgeons. At present, there is a relative paucity of evidence on best practice. This study sought to assess current national practice concerning perineal reconstruction following APE/ELAPE in the United Kingdom (UK) and to determine the factors involved in reconstruction choice.MethodologyAn anonymised survey was circulated to consultant plastic surgeons at all 48 UK centres performing perineal reconstruction following APE/ELAPE. Responses were collected between October 2021 and April 2022.ResultsComplete responses were received from 24 units nationally. All units had a dedicated APE/ELAPE service. Overall, 70% adopted a standardised reconstructive approach, the most common being the inferior gluteal artery perforator flap (n = 11). Significant variation was identified in the reconstructive technique. Similar differences were observed in the perceived importance of surgical factors guiding the reconstructive decision-making process, the top priorities being the size of the defect and previous radiotherapy.ConclusionsThe variability of responses suggests a lack of national consensus on optimal reconstruction following APE/ELAPE, despite the majority of centres employing a standardised approach to reconstruction. Our study highlights important surgical decision-making factors and provides valuable insight to aid in developing national collaborative evidence-based guidelines on best practice.

Clinical management of community-acquired meningitis in adults in the UK and Ireland in 2017: a retrospective cohort study on behalf of the National Infection Trainees Collaborative for Audit and Research (NITCAR)

ObjectivesTo assess practice in the care of adults with suspected community-acquired bacterial meningitis in the UK and Ireland.DesignRetrospective cohort study.Setting64 UK and Irish hospitals.Participants1471 adults with community-acquired meningitis of any...

Diagnosis, Therapy and Follow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry No. 032/033OL, May 2021) - Part 1 with Recommendations on Epidemiology, Screening, Diagnostics and Therapy.

Aim This update of the interdisciplinary S3 guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL) was published in March 2021. This updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German Society of Gynecology and Obstetrics ( Deutsche Gesellschaft für Gynäkologie und Geburtshilfe , DGGG) and the Working Group on Gynecological Oncology ( Arbeitsgemeinschaft Gynäkologische Onkologie , AGO) of the German Cancer Society ( Deutsche Krebsgesellschaft , DKG). Method The process of updating the S3 guideline dating from 2014 was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of existing evidence-based national and international guidelines or - if evidence was lacking - on a consensus of the specialists involved in compiling the update. After an initial review of the current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new recommendations or statements which took account of more recently published literature and the appraisal of the new evidence. Recommendations The short version of this guideline consists of recommendations and statements on the epidemiology, screening, diagnostic workup and therapy of patients with cervical cancer. The most important new aspects included in this updated guideline include the newly published FIGO classification of 2018, the radical open surgery approach for cervical cancers up to FIGO stage IB1, and use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated radiotherapy, image-guided adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.