Non-systematic Reviews Research Articles

What works to boost social relations and community wellbeing? A scoping review of the evidence

Background: Social relations are recognized as an important determinant of individual & community wellbeing. The UK What Works Wellbeing Centre chose “boosting social relations” as a priority topic for systematic review. First, a scoping review was undertaken to identify evidence gaps. Methods: We searched: Cochrane database of systematic reviews, DARE, Campbell Library, DoPHER (EPPI-Centre), Joanne Briggs Institute, MEDLINE, IDOX, CINAHL, PsycINFO, Social Policy & Practice, Social Care Online; relevant websites. Inclusion criteria: Population – communities in OECD countries; Intervention - Any community-based intervention, change in policy, organisation or environment that were designed to boost social relations within the community; Outcomes – social relations, community wellbeing or related synonyms; Study design – systematic & non-systematic reviews published between 2005 and 2016. Studies were selected & data extracted by 3 reviewers, and summarised narratively. Results: 11,257 titles and abstracts were screened, 182 obtained in full & 29 included. Existing evidence tells us: Targeted group interventions that foster social networks & provide meaningful roles can reduce social isolation and/ or loneliness in older people; Volunteering can improve physical & mental health & wellbeing in older people; Effective community engagement produces sustainable improvements in community health & individual wellbeing. Evidence gaps: Interventions for social isolation &/ or loneliness in adults aged up to 65 years; Volunteering in people aged up to 65 years; Social network analyses; Community infrastructure (places & spaces). Stakeholder consultations identified community infrastructure (places & spaces) as the most useful topic for systematic review. Conclusions: A systematic scoping review of reviews, with stakeholder consultation, identified community infrastructure (places & spaces) as an evidence gap. Early findings from the resulting systematic review will be presented.

Xerostomia and halitosis : A review and current concepts

Xerostomia is usually caused by a reduced salivary flow or by changes in the biochemical composition of saliva. Halitosis or oral malodor is an offensive odor usually originating from the oral cavity. Halitosis can lead to anxiety and psychosocial embarrassment. The occurrence of halitosis closely related with intraoral conditions including the presence of xerostomia. Especially, the relationship between xerostomia and halitosis is prominent in elderly patients receiving polypharmacy with at least two systemic diseases. This study is a review of the update literature of xerostomia and halitosis. A large number of papers have been searched and identified using the words <dry mouth>, <xerostomia>, <halitosis>, <elderly>, <causes>, <symptoms>, <treatment> and <dentistry>. Papers not relevant to the issue were removed reducing the entries to 79 only. Most of identified papers were systematic reviews, non-systematic reviews, and observational studies. With a proper diagnosis, identification of the etiology and timely referrals certain steps are taken to create a successful individualized therapeutic approach. It is significant to highlight the necessity of an interdisciplinary method for the treatment of xerostomia and halitosis to prevent misdiagnosis or unnecessary treatment. This article concisely focuses on the development of a systemic flow of events to come to the proper treatment of the xerostomia and halitosis.

Effect of nicotine replacement therapy on mortality, delirium, and duration of therapy in critically ill smokers: a systematic review and meta-analysis.

Nicotine replacement therapy is widely used in critically ill smokers and its effect on delirium, mortality and duration of intensive care unit (ICU) admission is unknown. The aims of this review were to determine whether the management of nicotine withdrawal with nicotine replacement therapy reduces delirium, mortality or length of stay in critically ill smokers in ICU. The primary outcome was incidence of author-defined ICU delirium. Secondary outcomes were ICU or hospital mortality, ICU-free days at day 28, and ICU or hospital length of stay. We conducted a systematic review and meta-analysis of the data sources MEDLINE, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews for randomised controlled trials and observational studies. Clinical trials, observational studies and systematic reviews comparing nicotine replacement therapy with placebo or no treatment were included. Case reports, case series, non-systematic reviews and studies that involved children were excluded. Eight studies were eligible (n=2,636) for inclusion in the data synthesis. In a meta-analysis of observational studies, nicotine replacement therapy was associated with increased delirium (three studies; n=908; I2=0%; finite element method: odds ratio 4.03 [95% confidence interval 2.64, 6.15]; P <0.001). There was no difference in ICU mortality (three studies; n=1,309; P=0.10, I2=44%; finite element method: odds ratio 0.58; 95% confidence intervals 0.31-1.10) and hospital mortality or 28-day ICU-free days. In the absence of high-quality data, nicotine replacement therapy cannot currently be recommended for routine use to prevent delirium or to reduce hospital or ICU mortality in critically ill smokers.

Treatment Options for Failed Back Surgery Syndrome Patients With Refractory Chronic Pain: An Evidence Based Approach.

A significant number of lumbar postsurgical patients continue to suffer persistent pain and limited function and are termed to have "Failed back surgery syndrome" (FBSS). This review evaluates clinical trial data for the treatment of FBSS patients. Using an evidence-based approach to evaluate FBSS treatments will assist clinicians in choosing the most effective options for FBSS patients. Furthermore, reducing the utilization of less effective therapies may result in substantial financial savings for this patient population. Treatments for FBSS may be generally categorized as physical therapy and exercise, medications, interventional procedures, neuromodulation, and reoperation. Careful review and classification of the level of evidence available for each category of treatment for FBSS patients will help guide clinical decision-making. A literature review was performed for FBSS treatments. The publications were arranged hierarchically according to the North American Spine Society's guidelines as randomized controlled trials (RCTs), prospective studies, retrospective chart, and systematic reviews. Book chapters, nonsystematic reviews, and expert opinions were excluded. The review focused on studies with at least 20 FBSS patients and 6-month follow-up. Evidence is weak for medications and reoperation, but strong for active exercise and interventional procedures such as adhesiolysis. The strongest evidence for long-term treatment is for spinal cord stimulation (SCS), showing favorable Level I RCT results compared with conventional medical management and reoperation. In addition, high-frequency SCS at 10 kHz has demonstrated superiority over traditional, low-frequency SCS for treating low back and leg pain in a recent Level I RCT. Clinicians may increasingly utilize levels of evidence during their evaluation of each FBSS patient to render the best therapeutic plan, likely resulting in improved long-term pain control and reducing costs by avoiding less effective modalities. New directions in SCS show promising results for the treatment of FBSS. 1.

No. 344-Opportunistic Salpingectomy and Other Methods of Risk Reduction for Ovarian/Fallopian Tube/Peritoneal Cancer in the General Population.

This guideline reviews the potential benefits of opportunistic salpingectomy to prevent the development of high grade serous cancers (HGSC) of the ovary/fallopian tube/peritoneum based on current evidence supporting the fallopian tube origin of disease. Gynaecologists, obstetricians, family doctors, registered nurses, nurse practitioners, residents, and health care providers. Adult women (18 and older): OPTIONS: Women considering hysterectomy who wish to retain their ovaries in situ have traditionally also retained their fallopian tubes. In addition, women undergoing permanent surgical sterilization have usually undergone tubal ligation using various methods rather than undergoing surgical removal of the entire fallopian tube. For the sections "Evidence Supporting the Hypothesis That HGSC Originates in the Fallopian Tube" and "Current Literature on the Effects and Safety of Opportunistic Salpingectomy," relevant studies were searched in PubMed, Medline, and the Cochrane Systematic Reviews using the following terms, either alone or in combination, with the search limited to English language materials: "high grade serous cancers ovary," "fallopian tube," "peritoneum," "opportunistic salpingectomy," "epithelial ovarian cancers," "origin," "tubal carcinoma in situ," "BRCA mutation," "prophylactic salpingectomy," "inflammation," "clear cell," and "endometrioid." The initial search was performed in March 2015 with a final literature search in March 2016. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. The total number of studies identified was 458, and 56 studies were included in this review. For the section "Other Factors Influencing the Risk of Developing "Ovarian" Cancers" a general Medline search was carried out using the terms "ovarian neoplasm" and "prevention." The search included papers published from December 2005 to March 2016. Meta-analyses were preferentially selected except where no such review was found. Additional searches for each subheading were also conducted (e.g., "ovarian neoplasm" and "tubal ligation.") Additional significant articles were identified through cross-referencing the identified reviews. For the search for "ovarian neoplasm" and "prevention," 10meta-analyses were identified. For the search for "ovarian neoplasm" and "tubal ligation," an additional 4 meta-analyses were identified. The content and recommendations were drafted and agreed on by the principal authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of the SOGC approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework (Table1). The interpretation of strong and weak recommendations is described in Table2. The summary of findings is available on request. The addition of opportunistic salpingectomy to a planned hysterectomy or permanent sterilization did not increase rates of hospital readmission (OR 0.91, 95% CI 0.75 to 1.10 and OR 0.8, 95% CI 0.56 to 1.21, respectively) or blood transfusions (OR 0.86, 95% CI 0.67 to 1.10 and OR 0.75, 95% CI 0.32 to 1.73, respectively) but did increase the overall operating time (by 16 minutes and 10 minutes, respectively) in a retrospective review of 43 931 women. The riskof repeat surgery for tubal pathology among women with retained fallopian tubes after hysterectomy was at least doubled (OR 2.13, 95% CI 1.88 to 2.42 in a population-based study of 170 000 women). If general gynaecologists were to consider removal of fallopian tubes at the time of every hysterectomy and sterilization procedure with referral of all patients with HGSC for hereditary cancer counselling and genetic testing, experts project a potential reduction in the rate of HGSC by 40% over the next 20years. Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. This guideline was developed with resources funded by the Society of Gynecologic Oncology of Canada and SOGC. RECOMMENDATIONS.

Proton pump inhibitors for functional dyspepsia.

Functional dyspepsia (FD or non-ulcer dyspepsia) is defined as continuous or frequently recurring epigastric pain or discomfort for which no organic cause can be found. Acid suppressive therapy, including proton pump inhibitors (PPIs), has been proposed as a therapeutic option in FD, but its efficacy remains controversial. While PPIs are generally considered safe and well tolerated, they have been associated with adverse events, especially in the long term. For this reason, decisions on whether to initiate or continue PPI therapy should be made based on an appropriate clinical indication. Therefore, we conducted a systematic review to evaluate whether PPI therapy provides symptomatic relief in FD. To determine the efficacy of proton pump inhibitors in the improvement of global symptoms of dyspepsia and quality of life compared to placebo, H2 receptor antagonists or prokinetics, in people with functional dyspepsia. We searched in the following electronic databases: the Cochrane Library (to January 2016), MEDLINE (OvidSP; to February 2016), Embase (OvidSP; to February 2016), and SIGLE grey literature (up to February 2016) and clinical trial registries; we handsearched abstracts from conferences up to February 2016. We screened non-systematic reviews, systematic reviews and guidelines to identify any additional trials. We contacted trialists to obtain missing information. All randomized controlled trials (RCTs) comparing any PPI with placebo, H2 receptor antagonists (H2RAs) or prokinetics for the treatment of FD. Participants were adults (aged 16 years or greater) with an adequate diagnosis of FD (any validated criteria such as Rome I, II, III or Lancet Working Group). Two review authors independently assessed eligibility, trial quality and extracted data. We collected data on dyspeptic symptoms, quality of life and number of overall adverse events. Specific adverse events werebeyond the scope of this review. We identified 23 RCTs from 22 papers (with 8759 participants) studying the effect of PPIs versus placebo, H2RAs or prokinetics for improvement of global symptoms of dyspepsia and quality of life in people with FD. Low-dose PPIs had similar efficacy as standard-dose PPIs, therefore we combined these subgroups for the analysis. Two to eight weeks of therapy with PPI was slightly more effective than placebo at relieving overall dyspepsia symptoms in people with FD (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.82 to 0.94; participants = 5968; studies = 16; number needed to treat for an additional beneficial outcome (NNTB) 13; moderate quality evidence). PPIs may be slightly more effective than H2RAs (RR 0.88, 95% CI 0.74 to 1.04; participants = 740; studies = 2, NNTB 13; low quality evidence), and slightly more effective than prokinetics (RR 0.90, 95% CI 0.81 to 1.00; participants = 892; studies = 4; NNTB 20; low quality evidence) at relieving overall dyspepsia symptoms in people with FD. PPIs plus prokinetics were possibly slightly more effective than PPIs alone at relieving overall dyspepsia symptoms (RR 0.85, 95% CI 0.68 to 1.08; participants = 407; studies = 2; NNTB 18; moderate quality evidence).The was no difference when subgrouped by Helicobacter pylori status, country of origin, or presence of reflux or Rome III subtypes. There were no differences in the number of adverse events observed between PPIs and any of the other treatments. There is evidence that PPIs are effective for the treatment of FD, independent of the dose and duration of treatment compared with placebo. PPIs may be slightly more effective than H2RAs for the treatment of FD; however, the evidence is scarce. The trials evaluating PPIs versus prokinetics are difficult to interpret as they are at risk of bias. Although the effect of these drugs seems to be small, the drugs are well tolerated.

Evaluating the Research Quality of Education Journals in China: Implications for Increasing Global Impact in Peripheral Countries

There has been a rapid growth of academic research and publishing in non-Western countries. However, academic journal articles in these peripheral countries suffer from low citation impact and limited global recognition. This critical review systematically analyzed 1,096 education research journal articles that were published in China in a 10-year span using a multistage stratified cluster and random sampling method and a validated rubric for assessing research quality. Our findings reveal that the vast majority of the articles lacked rigor, with insufficient or nonsystematic literature reviews, incomplete descriptions of research design, and inadequately grounded recommendations for translating research into practice. Acknowledging the differences in publishing cultures in the center-periphery divide, we argue that education research publications in non-Western countries should try to meet Western publishing standards in order to participate in global knowledge production and research vitality. Implications for emerging countries that strive to transform their research scholarship are discussed.

Monoclonal antibodies for chronic pain: a practical review of mechanisms and clinical applications.

ContextMonoclonal antibodies are being investigated for chronic pain to overcome the shortcomings of current treatment options.ObjectiveTo provide a practical overview of monoclonal antibodies in clinical development for use in chronic pain conditions, with a focus on mechanisms of action and relevance to specific classes.MethodsQualitative review using a systematic strategy to search for randomized controlled trials, systematic and nonsystematic (narrative) reviews, observational studies, nonclinical studies, and case reports for inclusion. Studies were identified via relevant search terms using an electronic search of MEDLINE via PubMed (1990 to June 2017) in addition to hand-searching reference lists of retrieved systematic and nonsystematic reviews.ResultsMonoclonal antibodies targeting nerve growth factor, calcitonin gene-related peptide pathways, various ion channels, tumor necrosis factor-α, and epidermal growth factor receptor are in different stages of development. Mechanisms of action are dependent on specific signaling pathways, which commonly involve those related to peripheral neurogenic inflammation. In clinical studies, there has been a mixed response to different monoclonal antibodies in several chronic pain conditions, including migraine, neuropathic pain conditions (e.g., diabetic peripheral neuropathy), osteoarthritis, chronic back pain, ankylosing spondylitis, and cancer. Adverse events observed to date have generally been mild, although further studies are needed to ensure safety of monoclonal antibodies in early stages of development, especially where there is an overlap with non-pain-related pathways. High acquisition cost remains another treatment limitation.ConclusionMonoclonal antibodies for chronic pain have the potential to overcome the limitations of current treatment options, but strategies to ensure their appropriate use need to be determined.

An overview of payment mechanisms and contractual models to support patient-centred care integration

The way health services are paid for will, directly or indirectly, influence what care is provided and the way it is delivered. Many countries are in the process of introducing policies and reforms to enhance collaboration across providers and foster integrated care. Interlinked with ambitions to create more patient-centered care are endeavors to change the health care purchasing model from one based largely on inputs and outputs to one based on outcomes, with the aim of optimising resource utilisation and improving care quality. This study gives an overview of current financial arrangements intended to support patient-centered care integration and reviews its evidence base. Within the broader meaning of integrated care, we focused on care continuity for patients with long-term illness and the vertical and horizontal integration of care across providers. We reviewed systematic and non-systematic reviews and overviews published in English between 2005 and 2015 in the scientific and gray literature. Financial arrangements to foster care integration span a continuum from direct financial incentives to encourage cooperation, across payment bundling, to population-based capitation; from the alignment of budgets and objectives, and sharing of financial risk and gains across providers, to full integration of funding and management: Paying physicians for care coordination can be a relatively straightforward first step towards care integration, specifically in settings where primary care physicians are paid by fee-for-service. In Austria, France and Germany, 'pay-for-coordination' schemes were applied as part of disease management programmes for selected chronic diseases in the early 2000s, later also in Denmark and Belgium. In systems based on fee-for-service or case-mix payments the (further) bundling of payments by episode or disease have been explored. In the US and Sweden, payment bundling has mainly been used for care episodes; for complex operative procedures to include also rehabilitation and readmission. In The Netherlands, a condition-specific bundled payment model, spanning across primary care providers, was introduced in 2007; initially under a pilot scheme for diabetes and in 2010 expanded to encompass chronic obstructive pulmonary and cardiovascular disease. The bundled payment model in The Netherlands is seen as a step towards introducing population-based capitation payment, where a fixed amount of funding, defined by age, medical conditions etc., is provided to cover the medical needs of each individual in a defined population, during a certain time period. Capitation payment can facilitate care integration, but can be difficult to manage across non-integrated providers which may have underlying disparate financial objectives. In the US, capitation models were explored in the 1980s and 1990s under the concept of 'managed care'. Many failed, arguably because of a lacking systems perspective with difficulties of balancing the interests of partners. Further, optimal care provision was not incentivised as there were few quality measures in the contracts. However, two US provider groups with long-term operations under capitation are the Veterans Health Administration and Kaiser Permanente. Contractual models, where financial risks and gains are shared across providers and payer with more or less formal agreements, include shared-savings, gain-sharing and alliance contracts. Accountable Care Organisations in the US, payer-provider alliances gradually introduced following the Affordable Care Act in 2010, often operate under shared-savings contracts. A regulatory change in Germany in 1999 that allowed for integrated care contracts between insurance funds and providers have resulted in a few population-based integrated care programmes, such as Gesundes Kinzigtal which applies a shared-savings model. In Canterbury in New Zealand, the health board has since the mid-2000s established alliance contracts with pre-agreed gain and losses dependent on the overall performance of involved service providers, aiming for a 'high trust, low bureaucracy' approach to contracting. There is to date little rigorous evidence of the health impact of different financial arrangements to support care integration. Disentangling the benefits or side effects of a financial model per se within the complexity of a healthcare restructuring is often difficult. As financial rewards may create strong incentives, consideration and assessment of how they may change behaviour and performance is necessary upon implementation. This is evidently also applicable to current financial models; reforms may be difficult to implement unless existing underlying incentive structures are properly addressed and considered. Operating new payment systems is likely to add transaction cost and one should be realistic about the time and costs it takes to develop capabilities to manage comprehensive payment models, such as population-based payment. What financial arrangement is most appropriate is highly context-dependent and experiences from one setting is often not directly transferable to other settings; integration requires flexibility and adaptation to local contexts, patients and other stakeholders.

Development of a Search Strategy for an Evidence Based Retrieval Service.

BackgroundPhysicians are often encouraged to locate answers for their clinical queries via an evidence-based literature search approach. The methods used are often not clearly specified. Inappropriate search strategies, time constraint and contradictory information complicate evidence retrieval.AimsOur study aimed to develop a search strategy to answer clinical queries among physicians in a primary care settingMethodsSix clinical questions of different medical conditions seen in primary care were formulated. A series of experimental searches to answer each question was conducted on 3 commonly advocated medical databases. We compared search results from a PICO (patients, intervention, comparison, outcome) framework for questions using different combinations of PICO elements. We also compared outcomes from doing searches using text words, Medical Subject Headings (MeSH), or a combination of both. All searches were documented using screenshots and saved search strategies.ResultsAnswers to all 6 questions using the PICO framework were found. A higher number of systematic reviews were obtained using a 2 PICO element search compared to a 4 element search. A more optimal choice of search is a combination of both text words and MeSH terms. Despite searching using the Systematic Review filter, many non-systematic reviews or narrative reviews were found in PubMed. There was poor overlap between outcomes of searches using different databases. The duration of search and screening for the 6 questions ranged from 1 to 4 hours.ConclusionThis strategy has been shown to be feasible and can provide evidence to doctors’ clinical questions. It has the potential to be incorporated into an interventional study to determine the impact of an online evidence retrieval system.

Algorithm for Choosing the Study Design in Systematic Reviews

Background: The Federal Joint Committee (Gemeinsamer Bundesausschuss) assigns the highest evidence level of Ia to systematic reviews of randomized controlled trials in evaluating the benefit of therapeutic interventions. Contradictory results among randomized and non-randomized studies may not always be caused by the study design. Methods: The objective of the study was to identify statements in systematic or non-systematic reviews about the choice of study designs in systematic reviews. Another objective was to develop an algorithm to facilitate the choice of appropriate study designs in systematic reviews. Results: The inclusion of non-randomized in addition to randomized study designs was supported by 85% of the 42 identified articles. A strong reason was the need to evaluate the possible treatment-associated harm. The developed algorithm included the 4 decision points of length of follow-up, frequency of events, outcomes, and study designs. Conclusions: If the benefit and the harm of a therapeutic intervention is planned to be evaluated, then often multiple study designs are required to be included. The algorithm provides guidance on which study designs should be considered for inclusion in systematic reviews.

Financial competing interests were associated with favorable conclusions and greater author productivity in nonsystematic reviews of neuraminidase inhibitors

ObjectiveTo characterize the conclusions and production of nonsystematic reviews about neuraminidase inhibitors relative to financial competing interests held by the authors. Study Design and SettingWe searched for articles about neuraminidase inhibitors and influenza (January 2005 to April 2015), identifying nonsystematic reviews and grading them according to the favorable/nonfavorable presentation of evidence on safety and efficacy. We recorded financial competing interests disclosed in the reviews and from other articles written by their authors. We measured associations between competing interests, author productivity, and conclusions. ResultsAmong 213 nonsystematic reviews, 138 (65%) presented favorable conclusions. Financial competing interests were identified for 26% (137/532) of authors; 51% (108/213) of reviews were associated with a financial competing interest. Reviews produced exclusively by authors with financial competing interests (33%; 71/213) were more likely to present favorable conclusions than reviews with no competing interests (risk ratio 1.27; 95% confidence interval 1.03–1.55). Authors with financial competing interests published more articles about neuraminidase inhibitors than their counterparts. ConclusionHalf of nonsystematic reviews about neuraminidase inhibitors included an author with a financial competing interest. Reviews produced exclusively by these authors were more likely to present favorable conclusions, and authors with financial competing interests published a greater number of reviews.

On the benefits of systematic reviews for wildlife parasitology.

Systematic reviews and meta-analyses are widely accepted as the best means to synthesise quantitative or qualitative scientific evidence. Many scientific fields have embraced these more rigorous review techniques as a means to bring together large and complex bodies of literature and their data. Unfortunately, due to perceived difficulties and unfamiliarity with processes, other fields are not using these options to review their literature. One way to provide guidance for a specific field is to examine critically recent reviews and meta-analyses and to explain the advantages and disadvantages of the various review techniques. In this paper, we examine review papers in the emerging field of wildlife parasitology and compare five different literature review types—configurative narrative review, aggregative scoping review, aggregative literature review, aggregative meta-analysis, and aggregative systematic review. We found that most literature reviews did not adequately explain the methodology used to find the literature under review. We also found that most literature reviews were not comprehensive nor did they critically appraise the literature under review. Such a lack severely reduces the reliability of the reviews. We encourage all authors to consider using systematic reviews in the future, and for authors and peer-reviewers to be aware of the limitations of non-systematic reviews.

PMD66 - HEARING RESTORATION, QUALITY OF LIFE, AND SAFETY OUTCOMES IN BONE-CONDUCTION DEVICES FOR PATIENTS WITH CONDUCTIVE OR MIXED HEARING LOSS OR SINGLE-SIDE DEAFNESS

To provide a comprehensive literature review on the various bone-conduction devices (BCDs) available, including bone-anchored hearing aids (BAHAs). A comprehensive search strategy was defined to perform a literature review of the data available to date on the different types of marketed BCDs for hearing rehabilitation in patients presenting with conductive hearing loss (CHL), mixed hearing loss (MHL), or single-side deafness (SSD). A search was conducted on December 22nd, 2015 on the PubMed, EMBASE and Google Scholar databases. Search criteria included patients presenting with CHL, MHL or SSD, and implanted with percutaneous (pBCI) or transcutaneous (tBCI) bone conduction implants. Non-systematic reviews, case reports and clinical studies on <5 patients were excluded. The literature analysis specifically examined the type of implantation (pBCI vs. tBCI), the principle of operation (active device, i.e. direct drive to the skull bone vs. passive device, i.e. skin drive), or by indication. 1,223 potentially relevant publications were identified; on full review, 95 studies met eligibility criteria. Hearing restoration, QoL and patient-reported outcomes measures have been increasingly documented for each technology in recent years. While the tBCIs seemed to be associated with a lower rate of skin complications than pBCIs, all the other parameters (clinical outcomes and QoL) seemed to be similarly distributed across all devices. The available data are still insufficient and the measurements’ sensitivities do not allow for a robust comparison between the different types of implants. The evidence base to support any differentiation between ‘passive’ and ‘active’ implants is insufficient, and direct comparison data is scarce. Future clinical studies and case reports should continue to investigate the clinical efficacy and safety outcomes related to the use of these devices, so as to provide physicians a more refined patient selection rationale and evidence-based practice pathways according to each device’s characteristics.

Use of Intravenous Fat Emulsion in the Emergency Department for the Critically Ill Poisoned Patient

BackgroundMultiple case reports of using intravenous fat emulsion (IFE) as an antidote for human poisoning from various xenobiotics have been published over the last decade. Given the rapidly evolving field, emergency physicians may be uncertain about the indications, timing, and dose for IFE treatment. MethodsA PubMed literature search was conducted from January 1996 to November 2015 and limited to human studies written in English and articles with relevant keywords. Guideline statements and nonsystematic reviews were excluded. Studies identified then underwent a structured review of their results. ResultsThere were 986 papers fulfilling the search criteria screened, and 85 appropriate articles were rigorously reviewed in detail. Recommendations were given on indications, timing, and dose of IFE. Most of these were based on case reports and anecdotal experience. DiscussionIn critically ill patients with refractory shock or cardiac arrest after a suspected overdose of local anesthetics or selected xenobiotics, IFE may be considered as a potentially beneficial adjunctive treatment. Despite an abundance of reports on the use of IFE on xenobiotics poisoning, the quality of evidence is suboptimal and fraught with reporting bias. ConclusionsIFE may be an effective antidote in poisonings from various xenobiotics. However, further research is needed to determine its optimal circumstances, timing, and dose of use.

IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes.

RecommendationsClassification/diagnosis Diabetic foot infection must be diagnosed clinically, based on the presence of local or systemic signs or symptoms of inflammation (strong; low). Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme (strong; moderate). Osteomyelitis For an infected open wound, perform a probe‐to‐bone test; in a patient at low risk for osteomyelitis, a negative test largely rules out the diagnosis, while in a high‐risk patient, a positive test is largely diagnostic (strong; high). Markedly elevated serum inflammatory markers, especially erythrocyte sedimentation rate, are suggestive of osteomyelitis in suspected cases (weak; moderate). A definite diagnosis of bone infection usually requires positive results on microbiological (and, optimally, histological) examinations of an aseptically obtained bone sample, but this is usually required only when the diagnosis is in doubt or determining the causative pathogen's antibiotic susceptibility is crucial (strong; moderate). A probable diagnosis of bone infection is reasonable if there are positive results on a combination of diagnostic tests, such as probe‐to‐bone, serum inflammatory markers, plain X‐ray, magnetic resonance imaging (MRI) or radionuclide scanning (strong; weak). Avoid using results of soft tissue or sinus tract specimens for selecting antibiotic therapy for osteomyelitis as they do not accurately reflect bone culture results (strong; moderate). Obtain plain X‐rays of the foot in all cases of non‐superficial diabetic foot infection (strong; low). Use MRI when an advanced imaging test is needed for diagnosing diabetic foot osteomyelitis (strong; moderate). When MRI is not available or contraindicated, consider a white blood cell‐labelled radionuclide scan, or possibly single‐photon emission computed tomography (CT) and CT (SPECT/CT) or fluorine‐18‐fluorodeoxyglucose positron emission tomography/CT scans (weak; moderate). Assessing severity At initial evaluation of any infected foot, obtain vital signs and appropriate blood tests, debride the wound and probe and assess the depth and extent of the infection to establish its severity (strong; moderate). At initial evaluation, assess arterial perfusion and decide whether and when further vascular assessment or revascularization is needed (strong; low). Microbiological considerations Obtain cultures, preferably of a tissue specimen rather than a swab, of infected wounds to determine the causative microorganisms and their antibiotic sensitivity (strong; high). Do not obtain repeat cultures unless the patient is not clinically responding to treatment, or occasionally for infection control surveillance of resistant pathogens (strong; low). Send collected specimens to the microbiology laboratory promptly, in sterile transport containers, accompanied by clinical information on the type of specimen and location of the wound (strong; low). Surgical treatment Consult a surgical specialist in selected cases of moderate, and all cases of severe, diabetic foot infection (weak; low). Perform urgent surgical interventions in cases of deep abscesses, compartment syndrome and virtually all necrotizing soft tissue infections (strong; low). Consider surgical intervention in cases of osteomyelitis accompanied by spreading soft tissue infection, destroyed soft tissue envelope, progressive bone destruction on X‐ray or bone protruding through the ulcer (strong; low). Antimicrobial therapy While virtually all clinically infected diabetic foot wounds require antimicrobial therapy, do not treat clinically uninfected wounds with antimicrobial therapy (Strong; Low) Select specific antibiotic agents for treatment based on the likely or proven causative pathogens, their antibiotic susceptibilities, the clinical severity of the infection, evidence of efficacy of the agent for diabetic foot infection and costs (strong; moderate). A course of antibiotic therapy of 1–2 weeks is usually adequate for most mild and moderate infections (strong; high). Administer parenteral therapy initially for most severe infections and some moderate infections, with a switch to oral therapy when the infection is responding (strong; low). Do not select a specific type of dressing for a diabetic foot infection with the aim of preventing an infection or improving its outcome (strong; high). For diabetic foot osteomyelitis, we recommend 6 weeks of antibiotic therapy for patients who do not undergo resection of infected bone and no more than a week of antibiotic treatment if all infected bone is resected (strong; moderate). We suggest not using any adjunctive treatments for diabetic foot infection (weak; low). When treating a diabetic foot infection, assess for use of traditional remedies and previous antibiotic use and consider local bacterial pathogens and their susceptibility profile (strong; low).

Expectation of sickness absence duration: a review on statements and methods used in guidelines in Europe and North America.

Background: Certifying physicians play a key role in the management of sickness absence and are often provided with guidelines. Some of these guidelines contain statements on expected sickness absence duration, according to diagnosis. We were interested in exploring the evidence base of these statements. Methods: We identified guidelines through a survey of EUMASS members and a literature search of the Internet and PubMed. We extracted the statements and methods from the guidelines. We compared: diagnoses that were addressed, expected durations and development processes followed. Next, we presented our findings to the developers, to afford them an opportunity to comment and/or correct any misinterpretations. Results: We identified 4 guidelines from social insurance institutions (France, Serbia, Spain and Sweden) and 4 guidelines from private organisations (1 Netherlands, 3 US). Guidelines addressed between 63 and some 63000 health conditions (ICD 10 codes). Health conditions overlapped among guidelines. Direct comparison is hampered by differences in coding (ICD 9 or 10) and level of aggregation (three or four digit, clustering of diseases and treatment situations). Expectations about duration are defined as minimum, maximum, and optimum or mean or median and percentile distribution, stratified to age and work requirements. In a sample of 5 diagnoses we found overlap in expected duration but also differences. Guidelines are developed differently, pragmatic expert consensus being used most, supplemented with data on sickness absence from different registers, other guidelines and non-systematic literature reviews. The effectiveness of these guidelines has not yet been formally evaluated. Conclusions: Expectations about duration of sickness absence by diagnosis are expressed in several guidelines. The expectations are difficult to compare, their evidence base is unclear and their effectiveness needs to be established.

Increase in quality and quantity of orthopaedic studies from 2002 to 2012.

To compare the level of evidence of orthopaedic studies published in 2002 and 2012 to determine whether the quality and quantity of studies have increased. The top 10 orthopaedic journals in 2002 and 2012 were identified, according to the Thomson Reuters impact factor. The level of evidence of each clinical article between January and June in 2002 and 2012 were determined by 2 senior orthopaedic trainees, according to the Oxford Centre for Evidence-based Medicine 2011 Levels of Evidence. Basic science articles, case reports, and non-systematic reviews were excluded. The proportions of papers designated to each level of evidence in 2002 and 2012 were compared, as was the mean level of evidence of studies in 2002 and 2012. In 2002, 379 clinical articles were identified and their level of evidence was level 1 (n=3), level 2 (n=67), level 3 (n=71), and level 4 (n=238). In 2012, 642 clinical articles were identified and their level of evidence was level 1 (n=26), level 2 (n=113), level 3 (n=167), and level 4 (n=336). The proportion of level 4 articles decreased from 62.8% in 2002 to 52.3% in 2012 (p=0.001), whereas the proportion of level 1 articles increased from 0.8% to 4.1% (p=0.002) and level 3 articles increased from 18.7% to 26.0% (p=0.008). The mean level of evidence improved from 3.44 in 2002 to 3.27 in 2012 (p=0.002). The quality and quantity of orthopaedic studies have increased from 2002 to 2012, but most studies remained of a low level of evidence.

Evidence for Autonomic Function and Its Influencing Factors in Subjects With COPD: A Systematic Review.

Cardiovascular autonomic neuropathy is one of the factors implicated in the high morbidity and mortality rate in patients with COPD. Thus, several studies and nonsystematic reviews have increasingly reported autonomic function impairment in these subjects. For a better understanding, this systematic review was performed to evaluate not only the evidence for autonomic function impairment, but also factors influencing it. The results of the studies reviewed showed a strong level of evidence to support the impairment of heart rate variability in the time domain. A similar evidence level was also found to support impairment in baroreceptor sensitivity and muscle sympathetic nerve activity. Furthermore, this review identified physical activity level, muscle function, and circadian rhythm as the major influencing factors (strong evidence) of autonomic function in subjects with COPD. However, no definite conclusion could be reached for factors such as dyspnea, anxiety, body composition, pulmonary function, age, breathing frequency, ventilatory effort, quality of life, and disease severity due to limited, conflicting, or lack of existing evidence. The results of this review highlight relevant clinical messages for clinicians and other health-care providers regarding the role autonomic function can play as an important physiological marker for prognostication and stratification. Hence, autonomic function outcomes should be identified and considered during management of patients with COPD. Moreover, this review can serve as basis for future research aimed at assessing the interventions for autonomic function abnormalities in these patients.

Telephone support and adherence in patients with chronic disease &amp;ndash; a qualitative review of reviews

Telephone support and adherence in patients with chronic disease &ndash; a qualitative review of reviews Divya Balasubramanian,1 Joanne Yoong,1&ndash;3 Hubertus JM Vrijhoef1,3&ndash;6 1Saw Swee Hock School of Public Health, National University Singapore, Singapore; 2Center for Economic and Social Research, University of Southern California, California, USA; 3Center for Health Services and Policy Research, National University Health System, Singapore; 4Scientific Center for Care and Welfare, Tilburg University, Tilburg, The Netherlands; 5Department of Patients &amp; Care, Maastricht University Medical Center, Maastricht, The Netherlands; 6Department of Family Medicine and Chronic Care, Vrije Universiteit Brussels, Brussels, Belgium Abstract: Among patients with a chronic disease, low adherence to prescribed treatments is very common, leading to substantial morbidity, mortality, and increase in health care costs. Telephone or mobile phone support is a common form of intervention that can be used to improve their adherence. We reviewed existing systematic and nonsystematic reviews to analyze the effectiveness of telephone interventions to improve treatment adherence in patients with chronic disease. Secondary aims were to evaluate the selected reviews in terms of cost-effectiveness of the intervention and frequency of messages affecting the adherence outcomes. A search for reviews was conducted in three databases, including PubMed, the Cochrane Library, and CINAHL, and three reviews that met the inclusion criteria were selected for final analysis. A qualitative review of the selected reviews was conducted, and reviews were evaluated to extract and summarize the characteristics and outcomes. Two of the selected reviews studied mobile phone text messaging, and one review studied telephone or mobile phone consultation. All three reviews reported an overall improvement in adherence, but the reviews varied in the types of research and the outcome measures. However, none of the reviews reported costs as an outcome. The evidence from reviews to characterize the effectiveness or cost-effectiveness of telephone support as an intervention to improve adherence among people with chronic diseases is fairly small and weak. Telephone support interventions have to be evaluated more systematically in routine practice against a comprehensive set of criteria, including their relative costs and outcomes. Keywords: literature review, compliance, telemedicine, communicable diseases, cost-effectiveness