Patient, Intervention, Comparison, Outcome Research Articles

The Effect of Isotretinoin on Insulin Resistance and Serum Adiponectin Levels in Acne Vulgaris Patients: A Systematic Review and Meta-Analysis.

Isotretinoin is the drug of choice for severe acne. We sought to examine the potential link between isotretinoin and insulin resistance. We conducted a systematic review and meta-analysis in accordance with the PRISMA statement. A comprehensive search of the PubMed/MEDLINE, SCOPUS, and Cochrane databases was performed until 12 January 2022 utilizing the PICO (Patient, Intervention, Comparison, Outcome) tool. Fifteen English-language studies focusing on isotretinoin-treated acne patients were included. Serum levels of insulin, glucose, and adiponectin were evaluated before and after treatment, and insulin sensitivity was assessed using the HOMA-IR. A meta-analysis was conducted using RevMan 5.4.1 software, and a quality assessment was undertaken using the ROBINS-I tool. The meta-analysis unveiled a statistically significant rise in the post-treatment levels of adiponectin, an anti-inflammatory agent, which inhibits liver glucose production while enhancing insulin sensitivity (SMD = 0.86; 95% confidence interval (95% CI) = 0.48-1.25, p-value < 0.0001; I2 = 58%). Our subgroup analysis based on study type yielded consistent findings. However, no statistically significant outcomes were observed for insulin, glucose levels, and the HOMA-IR. There is not a clear association between isotretinoin and insulin resistance, but it appears to enhance the serum levels of adiponectin, which participates in glucose metabolism.

Evidence‐based management strategies for endocrine complications after pituitary adenoma surgery

AbstractThis study aims to provide a clinical reference for the management of endocrine complications in pituitary tumor patients by synthesizing recent evidence for domestic and international management strategies. Based on the PIPOST (Population, Intervention, Professional, Outcome, Setting, and Type of Evidence) framework, evidence‐based medicine targets were determined. Electronic decision support systems, guideline websites, and databases were searched to identify the best evidence on postoperative endocrine complications in pituitary tumors. The PICO (Patient, Intervention, Comparison, Outcome) principle was used to construct the search strategy, and the studies from the past 10 years (July 2013 to July 2023) were included. A total of 11 articles were included, including four guidelines, two expert consensus statements, one systematic review, one best practice article, and three randomized controlled trials. We obtained evidence on five aspects (endocrine assessment, secondary adrenal insufficiency management, water metabolism disorder management, special population management, and follow‐up management) with a total of 30 pieces of evidence. Clinical healthcare professionals should focus on the care and follow‐up of patients with postoperative complications, such as adrenal insufficiency, temporary or permanent diabetes insipidus, and hyponatremia. Future research should involve large sample sizes, long‐term follow‐ups, and multicenter studies to further clarify the protocols for fluid restriction, diet, and hormone use.

Oral anticoagulants versus vitamin K antagonists in the treatment of non-valvular atrial fibrillation in patients with stage 4-5 chronic kidney disease

Aim. To compare the effectiveness and safety of direct oral anticoagulants (DOACs) with a vitamin K antagonist (VKA) in patients with atrial fibrillation (AF) and stage 4 and 5 chronic kidney disease (CKD).Material and methods. We searched in the PubMed, Google Scholar, and Web of Science databases from 1990 to 2022 for studies that compared DOACs with VKAs in patients with AF and stage 4 and 5 CKD. The patient, intervention, comparison, outcome (PICO) search strategy was used. Data were extracted by independent researchers and meta-analyzed.Results. A total of 6 studies were included in this meta-analysis. In terms of effectiveness, DOACs were comparable to VKAs. In terms of safety, DOACs and VKAs also had no statistical differences in hemorrhagic stroke, minor/gastrointestinal bleeding, overall mortality, but there was statistical significance in major bleeding. Conclusion. In terms of efficacy and safety, in general, DOACs were comparable to VKAs, but there were a number of following differences: the administration of DOACs to patients with stage 4 and 5 CKD, as well as those on hemodialysis, was accompanied by a significant reduction in the number of major bleedings, compared with warfarin therapy.

Gamification and Oral Health in Children and Adolescents: Scoping Review.

Oral health is a determinant of overall well-being and quality of life. Individual behaviors, such as oral hygiene and dietary habits, play a central role in oral health. Motivation is a crucial factor in promoting behavior change, and gamification offers a means to boost health-related knowledge and encourage positive health behaviors. This study aims to evaluate the impact of gamification and its mechanisms on oral health care of children and adolescents. A systematic search covered multiple databases: PubMed/MEDLINE, PsycINFO, the Cochrane Library, ScienceDirect, and LILACS. Gray literature, conference proceedings, and WHOQOL internet resources were considered. Studies from January 2013 to December 2022 were included, except for PubMed/MEDLINE, which was searched until January 2023. A total of 15 studies were selected following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The eligibility criteria were peer-reviewed, full-text, and empirical research related to gamification in oral health care, reports of impact, and oral health care outcomes. The exclusion criteria encompassed duplicate articles; unavailable full texts; nonoriginal articles; and non-digital game-related, non-oral health-related, and protocol studies. Selected studies were scrutinized for gamification mechanisms and outcomes. Two main questions were raised: "Does gamification in oral health care impact oral health?" and "Does oral health care gamification enhance health promotion and literacy?" The PICO (Patient, Intervention, Comparison, Outcome) framework guided the scoping review. Initially, 617 records were obtained from 5 databases and gray literature sources. After applying exclusion criteria, 15 records were selected. Sample size in the selected studies ranged from 34 to 190 children and adolescents. A substantial portion (11/15, 73%) of the studies discussed oral self-care apps supported by evidence-based oral health. The most clearly defined data in the apps were "brushing time" (11/11, 100%) and "daily amount brushing" (10/11, 91%). Most studies (11/15, 73%) mentioned oral health care behavior change techniques and included "prompt intention formation" (11/26, 42%), "providing instructions" (11/26, 42%), "providing information on the behavior-health link" (10/26, 38%), "providing information on consequences" (9/26, 35%), "modeling or demonstrating behavior" (9/26, 35%), "providing feedback on performance" (8/26, 31%), and "providing contingent rewards" (8/26, 31%). Furthermore, 80% (12/15) of the studies identified game design elements incorporating gamification features in oral hygiene applications. The most prevalent gamification features were "ideological incentives" (10/12, 83%) and "goals" (9/16, 56%), which were found in user-specific and challenge categories, respectively. Gamification in oral health care shows potential as an innovative approach to promote positive health behaviors. Most studies reported evidence-based oral health and incorporated oral health care behavior change techniques.

ERS/EBMT clinical practice guidelines on treatment of pulmonary chronic graft-versus-host disease in adults.

Chronic graft-versus-host disease (cGvHD) is a common complication after allogeneic haematopoietic stem cell transplantation, characterised by a broad disease spectrum that can affect virtually any organ. Although pulmonary cGvHD is a less common manifestation, it is of great concern due to its severity and poor prognosis. Optimal management of patients with pulmonary cGvHD is complicated and no standardised approach is available. The purpose of this joint European Respiratory Society (ERS) and European Society for Blood and Marrow Transplantation task force was to develop evidence-based recommendations regarding the treatment of pulmonary cGvHD phenotype bronchiolitis obliterans syndrome in adults. A multidisciplinary group representing specialists in haematology, respiratory medicine and methodology, as well as patient advocates, formulated eight PICO (patient, intervention, comparison, outcome) and two narrative questions. Following the ERS standardised methodology, we conducted systematic reviews to address these questions and used the Grading of Recommendations Assessment, Development and Evaluation approach to develop recommendations. The resulting guideline addresses common therapeutic options (inhalation therapy, fluticasone-azithromycin-montelukast, imatinib, ibrutinib, ruxolitinib, belumosudil, extracorporeal photopheresis and lung transplantation), as well as other aspects of general management, such as lung functional and radiological follow-up and pulmonary rehabilitation, for adults with pulmonary cGvHD phenotype bronchiolitis obliterans syndrome. These recommendations include important advancements that could be incorporated in the management of adults with pulmonary cGvHD, primarily aimed at improving and standardising treatment and improving outcomes.

Consensus-Based Overarching Principles and Recommendations on the Use of Biosimilars in the Treatment of Inflammatory Arthritis in the Gulf Region.

Though biologic agents have significantly improved the treatment of inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis), high costs, stringent regulations, strict reimbursement criteria, and existing patents have limited patient access to treatments. While being highly similar in quality, safety, and efficacy to biologic reference products, biosimilars can reduce the financial burden and prevent underutilization of medication. The objective of this initiative was to develop an evidence-based consensus of overarching principles and recommendations aimed at standardizing the use of biosimilars in treating inflammatory arthritis in the Gulf region. A task force of practicing rheumatologists, a clinical pharmacist, a health economist, patients, regulators, and payors from across the Gulf region developed recommendations and overarching principles based on the outputs of a systematic literature review conducted to address Patient-Intervention-Comparison-Outcome (PICO) questions specific to key challenges regarding the use of biosimilars for the treatment of inflammatory arthritis in the region. As the data before 2017 have been previously reviewed in another publication, the current review focused on data published between January 2017 and August 2022 (PROSPERO ID CRD42022364002). Consensus on each statement required a level of agreement of 70% or greater. Consensus was reached for five overarching principles and nine recommendations by the task force. The principles emphasize the importance of improving the awareness, understanding, and perception of biosimilars, as well as the need for regulated regional real-world data generation and protocols to make biosimilars a viable and affordable treatment option for all patients. The consensus recommendations advocate the need for shared treatment decisions between rheumatologists and patients when considering biosimilars. They further recommend that confirmation of a biosimilar's efficacy and safety in a single indication is sufficient for extrapolation to other diseases for which the reference product has been approved. Finally, there is a need for pharmacovigilance and national health policies governing the adoption and prescription of biosimilars in clinical practice across the region. These are the first consensus recommendations for the Gulf region based on a systematic literature review and Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines, integrating clinical evidence with clinical expertise to optimize decision making for the use of biosimilars in patients with inflammatory arthritis. They were formulated based on predominantly international data because of the limited regional data and therefore can be generalized to serve as recommendations for healthcare professionals in other parts of the world.

Systematic Review of In Vitro Studies on Distortion Generated by Intraoral Scanning Systems for Oral Rehabilitations with More Than Three Implants

(1) Background: This systematic review intends to answer the following Patient–Intervention–Comparison–Outcome (PICO) question: Do digital impression systems generate significant errors during scanning in extensive implant restorative treatments? (2) Methods: Following the PRISMA protocol and according to predefined inclusion criteria, two trained investigators searched for relevant articles in the PubMed database and related sources using a standard keyword sequence. The investigators were responsible for selecting studies and performing quality analysis. (3) Results: From 78 titles, only 9 studies were selected. An analysis of registration distortion variations was conducted for each potential influencing factor in terms of accuracy: interimplant distance, implant angulation, scanner type, and scanning body type. The results showed repeatable differences in accuracy between types of scanning technologies and techniques, and a positive correlation between interimplant distance and the amplitude of deviations detected in comparative analysis, with the highest error levels in total edentulous arch recording. There was no consensus on the error level owing to implant angulation, and statistically significant differences were found between the types of scan bodies used. (4) Conclusions: Digital impression systems generate significant errors during scanning in extensive implant restorative treatments, influenced by scanning technology, interimplant distance, and scanning body type.

2022 Peritoneal Surface Oncology Group International Consensus on HIPEC Regimens for Peritoneal Malignancies: Colorectal Cancer

BackgroundSelected patients with peritoneal metastases of colorectal cancer (PM-CRC) can benefit from potentially curative cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC), with a median overall survival (OS) of more than 40 months.ObjectiveThe aims of this evidence-based consensus were to define the indications for HIPEC, to select the preferred HIPEC regimens, and to define research priorities regarding the use of HIPEC for PM-CRC.MethodsThe consensus steering committee elaborated and formulated pertinent clinical questions according to the PICO (patient, intervention, comparator, outcome) method and assessed the evidence according to the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework. Standardized evidence tables were presented to an international expert panel to reach a consensus (4-point, weak and strong positive/negative) on HIPEC regimens and research priorities through a two-round Delphi process. The consensus was defined as ≥ 50% agreement for the 4-point consensus grading or ≥ 70% for either of the two combinations.ResultsEvidence was weak or very weak for 9/10 clinical questions. In total, 70/90 eligible panelists replied to both Delphi rounds (78%), with a consensus for 10/10 questions on HIPEC regimens. There was strong negative consensus concerning the short duration, high-dose oxaliplatin (OX) protocol (55.7%), and a weak positive vote (53.8–64.3%) in favor of mitomycin-C (MMC)-based HIPEC (preferred choice: Dutch protocol: 35 mg/m2, 90 min, three fractions), both for primary cytoreduction and recurrence. Determining the role of HIPEC after CRS was considered the most important research question, regarded as essential by 85.7% of the panelists. Furthermore, over 90% of experts suggest performing HIPEC after primary and secondary CRS for recurrence > 1 year after the index surgery.ConclusionsBased on the available evidence, despite the negative results of PRODIGE 7, HIPEC could be conditionally recommended to patients with PM-CRC after CRS. While more preclinical and clinical data are eagerly awaited to harmonize the procedure further, the MMC-based Dutch protocol remains the preferred regimen after primary and secondary CRS.

Role of Perfusion Index and Pulse Variability Index in the Assessment of Neonatal Hemodynamics: A Systematic Review.

Hemodynamic monitoring of neonates is crucial because neonates are easily and acutely susceptible to hemodynamic disturbances. As such, non-invasive monitoring of hemodynamics is preferable. It has been postulated that non-invasive pulse oximetry determines the perfusion index and pulse variability index and provides accurate measurements to predict hemodynamic changes in preterm or term infants. Equally, numerous studies have investigated the efficacy of perfusion and pulse variability indices in monitoring neonatal hemodynamics. The aim of this study was to systematically review studies that have delved into the role of perfusion and pulse variability indices in the assessment of neonatal hemodynamics. The study collected data from 2010-2023 using the patient, intervention, comparison, outcome (PICO) search strategy using the databases PubMed, Scopus, and Excerpta Medica database (Embase). A total of 616 articles were evaluated based on their appropriateness and relevance; we included seven studies. As per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review. Our study concluded that these indices were effective in measuring hemodynamics.

Expert opinion on evidence after the 2020 Korean Cardiopulmonary Resuscitation Guidelines: a secondary publication.

Considerable evidence has been published since the 2020 Korean Cardiopulmonary Resuscitation Guidelines were reported. The International Liaison Committee on Resuscitation (ILCOR) also publishes the Consensus on CPR and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) summary annually. This review provides expert opinions by reviewing the recent evidence on CPR and ILCOR treatment recommendations. The authors reviewed the CoSTR summary published by ILCOR in 2021 and 2022. PICO (patient, intervention, comparison, outcome) questions for each topic were reviewed using a systemic or scoping review methodology. Two experts were appointed for each question and reviewed the topic independently. Topics suggested by the reviewers for revision or additional description of the guidelines were discussed at a consensus conference. Forty-three questions were reviewed, including 15 on basic life support, seven on advanced life support, two on pediatric life support, 11 on neonatal life support, six on education and teams, one on first aid, and one related to COVID-19. Finally, the current Korean CPR Guideline was maintained for 28 questions, and expert opinions were suggested for 15 questions.

Development of the Italian clinical practice guidelines for the treatment of diabetic foot syndrome: design and methodological aspects.

Diabetic foot syndrome (DFS) and its complications are a growing public health concern. The Italian Society of Diabetology (SID) and the Italian Association of Clinical Diabetologists (AMD), in collaboration with other scientific societies, will develop the first Italian guidelines for the treatment of DFS. The creation of SID/AMD Guidelines is based on an extended work made by 19 panelists and 12 members of the Evidence Review Team. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide aims, reference population, and target health professionals. Clinical questions have been created using PICO (Patient, Intervention, Comparison, Outcome) conceptual framework. The definition of questions has been performed using a two-step web-based Delphi methodology, a structured technique aimed at obtaining by repeated rounds of questionnaires a consensus opinion from a panel of experts in areas wherein evidence is scarce or conflicting, and opinion is important. The mean age of panelists (26.3% women) was 53.7 ± 10.6years. The panel proposed 34 questions. A consensus was immediately reached for all the proposed questions, 32 were approved and 2 were rejected. The areas covered by clinical questions included diagnosis of ischemia and infection, treatment of ischemic, neuropathic, and infected ulcers, prevention of foot ulceration, organization and education issues, and surgical management. The PICO presented in this paper are designed to provide indications for healthcare professionals in charge of diabetic foot treatment and prevention, primarily based on clinical needs of people with diabetic foot syndrome and considering the existing organization of health care.

A Systematic Review and Meta-analysis on Stenting for Aortic Coarctation Management in Adults.

Endovascular treatment of aortic coarctation (CoA) constitutes a valuable alternative with low morbidity and mortality. The aim of this systematic review and meta-analysis was to assess the technical success, re-intervention, and mortality after stenting for CoA in adults. The Preferred Reporting Items for Systematic Reviews and Meta-analysis statement and PICO (patient, intervention, comparison, outcome) model were followed. An English literature data search was conducted, using PubMed, EMBASE, and CENTRAL, until December 30, 2021. Only studies reporting on stenting, for native or recurrent CoA, in adults were included. The risk of bias was assessed using the Newcastle-Ottawa Scale. A proportional meta-analysis was performed to assess the outcomes. Primary outcomes were technical success, intra-operative pressure gradient and complications, and 30-day mortality. Twenty-seven articles (705 patients) were included (64.0% males, 34.0±13.6 years). Native CoA was present in 65.7%. Technical success was 97% (95% confidence interval [CI], 0.96%-0.99%; p<0.001, I2=9.49%). Six (odds ratio [OR]: 1%; 95% CI, 0.00%-0.02%; p=0.002, I2=0%) ruptures and 10 dissections (OR: 2%; 95% CI, 0.001%-0.02%; p<0.001, I2=0%) were reported. The intra-operative and 30-day mortality were 1% (95% CI, 0.00%-0.02%; p=0.003, I2=0%) and 1% (95% CI, 0.00%-0.02%; p=0.004, I2=0%), respectively. The median follow-up was 29 months. Sixty-eight re-interventions (OR: 8%; 95% CI, 0.05%-0.10%; p<0.001, I2=35.99%) were performed; 95.5% were endovascular. Seven deaths were reported (OR: 2%; 95% CI, 0.00%-0.03%; p=0.008, I2=0%). Stenting for CoA in adults presents high technical success and the intra-operative and 30-day mortality rates were acceptable. During the midterm follow-up, the re-intervention rate was acceptable, and mortality was low. Aortic coarctation is a quite common heart defect that may be diagnosed in adult patients, as a first diagnosis in native cases or as a recurrent after previous repair. Endovascular management using plain angioplasty has been associated to a high intra-operative complication and re-intervention rate. Stenting in this analysis seems to be safe and effective as is related a high technical success rate, exceeding 95%, with a low intra-operative complication and death rate. During the mid-term follow-up, the re-interventions rate is estimated at less than 10% while most cases are managed using endovascular means. Further analyses are needed on the impact of stent type on endovascular repair outcomes.

Efficacy of varenicline versus bupropion for smoking cessation: A systematic review and meta-analysis of randomized controlled trials.

According to the Global Burden of Disease (GBD) Study conducted in 2019, smoking tobacco leads to over 8 million deaths each year. Hence, it is crucial to identify optimal smoking cessation therapy. To compare the efficacy of varenicline versus bupropion for smoking cessation by performing a meta-analysis of randomized controlled trials (RCTs). Protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO). The Patient intervention comparison outcome time (PICOT) format is used in the study. Patients having nicotine use disorder treated with varenicline or bupropion were included, and the continuous abstinence rate (CAR) was assessed at 12, 24, and 52 weeks. The PubMed and Google Scholar databases were systematically searched, and after the screening, RCTs involving a comparison of varenicline and bupropion in smoking cessation were included. We performed a meta-analysis of three RCTs (10110 patients) by RevMan 5.4.1 statistical software to determine the efficacy of varenicline compared with bupropion in smoking cessation. The CAR at 9- to 12-week follow-up of varenicline is superior to bupropion (OR = 1.79, CI range: 1.59-2.02, P < 0.001). Similarly, the CAR of varenicline is superior to bupropion for weeks 9-24 (1.51, 1.32 to 1.72) and weeks 9-52 (1.60, 1.22 to 2.12), suggesting the absolute advantage of varenicline over bupropion for smoking cessation in terms of efficacy. Both varenicline and bupropion are efficacious therapies for smoking cessation. Compared with bupropion, varenicline can significantly improve the CAR at the end of treatment, at 24 weeks, and at 52 weeks of follow-up.

A pipeline for medical literature search and its evaluation

One database commonly used by clinicians for searching the medical literature and practicing evidence-based medicine is PubMed. As the literature grows, it has become challenging for users to find the relevant material quickly because most of the time the relevant results are not on the top. In this article, we propose a search and ranking pipeline to improve the search results based on relevancy. We first propose an ensemble model consisting of three classifiers: bidirectional long-short-term memory conditional random field (bi-LSTM-CRF), support vector machine and naive Bayes to recognise PICO (patient, intervention, comparison, outcome) elements from abstracts. The ensemble was trained on an annotated corpus consisting of 5000 abstracts split into 4000 and 1000 training and testing data, respectively. The ensemble recorded an accuracy of 93%. We then retrieved around 927,000 articles from PubMed for the years 2017–2021 (access date 16 April 2021). For every abstract, we extracted and grouped all P, I and O terms, and stored these groups along with the article ID in a separate database. During the search, every P, I and O term of the query is searched only in its corresponding group of every abstract. The scoring method simply counts the number of matches between the query’s P, I and O elements and the words in P, I and O groups, respectively. The abstracts are sorted by the number of matches and the top five abstracts are listed using their pre-stored abstract IDs. A comprehensive user study was conducted where 60 different queries were formulated and used to generate ranked search results using both PubMed and our proposed model. Five medical professionals assessed the ranked search results and marked every item as relevant or non-relevant. Both models were compared using precision@K and mean-average-precision@K metrics where K is 5. For most of the queries, our model produced higher precision@K values than PubMed. The mean-average-precision@K value of our model is also higher than PubMed (0.83 versus 0.67).

Efficacy and Safety Comparison Between Lorazepam and Diazepam in Treating Convulsive Status Epilepticus in Children: An Evidence-Based Case Report

Introduction: Indonesia still recommends diazepam for epilepsy, but the International League Against Epilepsy increasingly favours lorazepam. Some reports indicate diazepam being less effective and causing side effects. This report presents a difficult-to-treat convulsive status epilepticus (CSE) case in a 10-month infant who received diazepam, questioning if intravenous/rectal lorazepam is a better initial therapy than diazepam for hospitalized children with CSE. Methods: Following the patient-intervention-comparison-outcome (PICO) formula, we searched for evidence in four journal databases (Pubmed, Proquest, EBSCOHost, and Cochrane). Studies meeting inclusion and exclusion criteria were appraised. Results: Through three systematic reviews and meta-analyses, our clinical query was addressed. One study revealed that rectal lorazepam was more effective in stopping seizures than rectal diazepam (RR 2.86). Meanwhile, two studies found that intravenous lorazepam exhibited similar efficacy in seizure cessation compared to intravenous diazepam (RR 1.04 and OR 1.03, respectively). Both drugs showed no significant difference in the time required to stop seizures or the necessity for additional doses or adjunctive medications to achieve such cessation, nor in the likelihood of refractory seizure within 24 hours. Two studies indicated that intravenous lorazepam had a reduced risk of respiratory depression (RR 0.71 and OR 0.62, respectively). Regardless of the administration route, lorazepam was linked to a lower probability of ICU admission (RR 0.15) than diazepam. Conclusion: Intravenous lorazepam and diazepam are equally effective for treating CSE, but rectal lorazepam is considered better at stopping seizures and preventing their recurrence compared to diazepam. Furthermore, lorazepam is deemed safer, especially when given intravenously.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12months old admitted to a pediatric critical care unit.

We present guidelines for the management of infants under 12months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines. Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology. This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting. These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Development of the Italian Clinical Practice Guidelines on Bariatric and Metabolic Surgery: Design and Methodological Aspects.

Obesity and its complications are a growing problem in many countries. Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) developed the first Italian guidelines for the treatment of obesity. The creation of SICOB Guidelines is based on an extended work made by a panel of 24 members and a coordinator. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide the aims, reference population, and target health professionals. Clinical questions have been created using the PICO (Patient, Intervention, Comparison, Outcome) conceptual framework. The definition of questions used the two-step web-based Delphi method, made by repeated rounds of questionnaires and a consensus opinion from the panel. The panel proposed 37 questions. A consensus was immediately reached for 33 (89.2%), with 31 approved, two rejected and three which did not reach an immediate consensus. The further discussion allowed a consensus with one approved and two rejected. The areas covered by the clinical questions included indications of metabolic/bariatric surgery, types of surgery, and surgical management. The choice of a surgical or a non-surgical approach has been debated for the determination of the therapeutic strategy and the correct indications.

Identifying and Prioritizing Research to Improve Emergency Care of Persons Living With Dementia: A Geriatric Emergency care Applied Research 2.0 Network ‐ Advancing Dementia Care (GEAR 2.0‐ADC) Scoping Review

AbstractBackgroundPersons living with dementia (PLWD) frequently access emergency departments (EDs) for care, but current research surrounding their unique care needs is limited. The Geriatric Emergency care Applied Research 2.0 Network–Advancing Dementia Care (GEAR 2.0‐ADC) aims to identify and prioritize research gaps surrounding the most important needs for PLWD to advance their emergency care.MethodA Task Force of 61 stakeholders including ED‐ and non‐ED‐based clinicians, PLWD, care partners, and advocacy organizations was established. Task Force members voted to choose the top four topics for investigation. Two Patient‐Intervention‐Comparison‐Outcome (PICO) questions were developed per topic. Following the PRISMA‐ScR guidelines and working with medical librarians, systematic literature searches and scoping reviews were completed by Task Force members. Findings were presented at the GEAR 2.0‐ADC Consensus Conference to the full Task Force. After discussion, they developed research questions for each topic area and voted to prioritize the questions within each topic area for future investigations.ResultsTask Force voting identified four critical topics for investigation and two unique PICO questions for each topic. The literature search and abstraction process comprehensively summarized the research to date for dementia detection (3,651 identified, 132 abstracted), communication and decision‐making (8,138 identified, 24 abstracted), ED clinical practices (6,348 identified, 23 abstracted), and care transitions from the ED to the community (3,484 identified, 10 abstracted). General themes that emerged from the abstraction process included a need for effective patient‐centered care interventions in the ED and when transitioning back to the community following care, identification of communication barriers between care partners and medical staff, measurement of dementia in the ED setting that is both efficient and operational, a need to decrease stimulation, and for increased PLWD and care partner engagement. The stakeholders rank‐voted the research questions developed for each topic, resulting in a framework for GEAR 2.0‐ADC’s support for future research.ConclusionTransdisciplinary stakeholders, PLWD, and care partners identified critical research topics and performed four scoping reviews, leading to refinement of the research gaps and prioritization for future research. These gaps will be addressed in upcoming GEAR 2.0‐ADC funding opportunities.

Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care.

Recent data indicated a high incidence of inappropriate management of neuromuscular block, with a high rate of residual paralysis and relaxant-associated postoperative complications. These data are alarming in that the available neuromuscular monitoring, as well as myorelaxants and their antagonists basically allow well tolerated management of neuromuscular blockade. In this first European Society of Anaesthesiology and Intensive Care (ESAIC) guideline on peri-operative management of neuromuscular block, we aim to present aggregated and evidence-based recommendations to assist clinicians provide best medical care and ensure patient safety. We identified three main clinical questions: Are myorelaxants necessary to facilitate tracheal intubation in adults? Does the intensity of neuromuscular blockade influence a patient's outcome in abdominal surgery? What are the strategies for the diagnosis and treatment of residual paralysis? On the basis of this, PICO (patient, intervention, comparator, outcome) questions were derived that guided a structured literature search. A stepwise approach was used to reduce the number of trials of the initial research ( n = 24 000) to the finally relevant clinical studies ( n = 88). GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was used for formulating the recommendations based on the findings of the included studies in conjunction with their methodological quality. A two-step Delphi process was used to determine the agreement of the panel members with the recommendations: R1 We recommend using a muscle relaxant to facilitate tracheal intubation (1A). R2 We recommend the use of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation (1C). R3 We recommend the use of a fast-acting muscle relaxant for rapid sequence induction intubation (RSII) such as succinylcholine 1 mg kg -1 or rocuronium 0.9 to 1.2 mg kg -1 (1B). R4 We recommend deepening neuromuscular blockade if surgical conditions need to be improved (1B). R5 There is insufficient evidence to recommend deep neuromuscular blockade in general to reduce postoperative pain or decrease the incidence of peri-operative complications. (2C). R6 We recommend the use of ulnar nerve stimulation and quantitative neuromuscular monitoring at the adductor pollicis muscle to exclude residual paralysis (1B). R7 We recommend using sugammadex to antagonise deep, moderate and shallow neuromuscular blockade induced by aminosteroidal agents (rocuronium, vecuronium) (1A). R8 We recommend advanced spontaneous recovery (i.e. TOF ratio >0.2) before starting neostigmine-based reversal and to continue quantitative monitoring of neuromuscular blockade until a TOF ratio of more than 0.9 has been attained. (1C).

Clinical management guidelines for Friedreich ataxia: best practice in rare diseases

BackgroundIndividuals with Friedreich ataxia (FRDA) can find it difficult to access specialized clinical care. To facilitate best practice in delivering healthcare for FRDA, clinical management guidelines (CMGs) were developed in 2014. However, the lack of high-certainty evidence and the inadequacy of accepted metrics to measure health status continues to present challenges in FRDA and other rare diseases. To overcome these challenges, the Grading of Recommendations Assessment and Evaluation (GRADE) framework for rare diseases developed by the RARE-Bestpractices Working Group was adopted to update the clinical guidelines for FRDA. This approach incorporates additional strategies to the GRADE framework to support the strength of recommendations, such as review of literature in similar conditions, the systematic collection of expert opinion and patient perceptions, and use of natural history data.MethodsA panel representing international clinical experts, stakeholders and consumer groups provided oversight to guideline development within the GRADE framework. Invited expert authors generated the Patient, Intervention, Comparison, Outcome (PICO) questions to guide the literature search (2014 to June 2020). Evidence profiles in tandem with feedback from individuals living with FRDA, natural history registry data and expert clinical observations contributed to the final recommendations. Authors also developed best practice statements for clinical care points that were considered self-evident or were not amenable to the GRADE process.ResultsSeventy clinical experts contributed to fifteen topic-specific chapters with clinical recommendations and/or best practice statements. New topics since 2014 include emergency medicine, digital and assistive technologies and a stand-alone section on mental health. Evidence was evaluated according to GRADE criteria and 130 new recommendations and 95 best practice statements were generated.Discussion and conclusionEvidence-based CMGs are required to ensure the best clinical care for people with FRDA. Adopting the GRADE rare-disease framework enabled the development of higher quality CMGs for FRDA and allows individual topics to be updated as new evidence emerges. While the primary goal of these guidelines is better outcomes for people living with FRDA, the process of developing the guidelines may also help inform the development of clinical guidelines in other rare diseases.