Clinical Guideline Recommendations Research Articles

Symptom Management Guideline Implementation Among Nurses in Cancer-Specific Outpatient Settings: A Scoping Review of Barriers, Facilitators, and Implementation Strategies.

Oncology outpatients experience high levels of distressing cancer-related symptoms. Nurses can provide high-quality outpatient cancer symptom management following clinical practice guideline recommendations; however, these guidelines are inconsistently used in practice. Understanding contextual factors influencing implementation is necessary to develop tailored implementation strategies. To identify and describe (1) barriers and facilitators influencing symptom management guideline adoption, implementation, and/or sustainability among nurses in cancer-specific outpatient settings and (2) components of strategies used to enhance guideline implementation. A scoping review was conducted following Joanna Briggs Institute methodology. CINAHL, EMBASE, EMCARE, MEDLINE, and gray literature sources were searched. Eligibility screening and data extraction were performed in duplicate. The updated Consolidated Framework for Implementation Research and Expert Recommendations for Implementing Change taxonomy informed data extraction and descriptive analysis. Thirty-six projects from 2004 to 2023 were included; most used quality improvement (n = 14) or quasi-experimental (n = 10) designs. Determinants were most often mapped to the "inner setting" and "individuals-roles/characteristics" Consolidated Framework for Implementation Research domains. Most projects used multiple discrete implementation strategies within the "train and educate stakeholders" (n = 29, 85%) and/or "develop stakeholder interrelationships" (n = 20, 59%) categories. Nurses may face several barriers to symptom management guideline implementation within cancer-specific outpatient setting workflows and may have limited opportunity to implement guidelines within their current roles. Most projects used educational strategies, which alone may be insufficient to address reported barriers. By identifying barriers, facilitators, and strategies, this scoping review can be used to design tailored strategies to implement symptom management guidelines within outpatient oncology nursing care.

International Society on Thrombosis and Haemostasis Clinical Practice Guideline for Treatment of Congenital Haemophilia-A Critical Appraisal.

Evidence-based clinical practice guidelines drive optimal patient care and facilitate access to high-quality treatment. Creating guidelines for rare diseases such as haemophilia, where evidence does not often come from randomized controlled trials but from non-randomized and well-designed observational studies and real-world data, is challenging. The methodology used for assessing available evidence should consider this critical fact. In formulating guidelines, it is essential to include treatment goals and patient preference. This paper comprehensively critiques, against this background, the recommendations of the ISTH clinical practice guidelines for the treatment of haemophilia. Each recommendation was critically reviewed against available evidence as well as existing guidelines and commented upon for its scientific validity, impact on clinical practice and access to care globally. The validity of the way in which the GRADE methodology was applied to existing evidence was also assessed. The critique provided shows that these recommendations have major limitations: they did not state treatment goals and contradict existing guidelines; opportunities for providing access to innovation were missed when the therapeutic benefits of the products approved in the last decades were not included. A major reason for this is the inappropriate adoption of the GRADE methodology without adaptations and without considering treatment goals and patient-relevant outcomes. These recommendations may mislead healthcare professionals, payers and governments and therefore cannot serve the patient community well. They setback the advances made in haemophilia care because they overlook important available evidence and do not guide clinical practice to contemporary standards.

Prioritization of research questions in health crises-presentation of aconcept developed during the COVID-19 pandemic

In acute crises such as the COVID-19 pandemic, scientific questions need to be addressed quickly in order to protect the health of the population and to maintain the function of the healthcare system. The prevailing urgency and the large number of issues to be addressed, combined with the limitation of time, personnel, or monetary resources make prioritization indispensable. In the COVID-19 Evidence Ecosystem (CEOsys) project initiated by the University Medicine Network (NUM), aprocedure for the rapid prioritization of questions was used specifically for evidence syntheses and clinical guideline recommendations, which was further developed in the follow-up project PREparedness and Pandemic Response in Germany (PREPARED).The result is aconcept paper on the prioritization of research questions and topics with amore generic orientation. The content of the concept is presented in this article. The core subjects are basic principles of successful prioritization as well as an explicit seven-step process with information on organizational framework conditions and the procedure. The concept offers possibilities for adaptation, as research prioritization is highly context-dependent.The application of such asystematic, transparent prioritization process contributes to comprehensible and informed decisions about which research questions are relevant and urgent, in which order they should be processed, and which issues are not critically urgent or have to be postponed.

Association Between the Dietary Practices and the Nutrition Status of Adult Cancer Outpatients at Nyeri County Referral Hospital, Kenya; A Cross Sectional Survey

The global attainment of the Sustainable Development Goal 3 target 3.4 has been slow, with a notable increase in the cancer burden. Besides the normal cancer pathogenesis, 5-10% of the total cancer cases develop as a result of sub-optimal diets and other lifestyle factors and therefore, consuming a healthy diet in adequate amounts helps in prevention of the tumor itself and cancer related malnutrition. Limited evidence exists on the link between dietary practices and the nutrition status of cancer patients, and this study sought to fill this gap using analytical cross-sectional study design. Data was collected using a 24-hour recall, Food Frequency Questionnaire and Malnutrition Universal Screening Tool. The dietary patterns identified from the research were, excessive consumption of foods from the starchy foods and the fats category (65.1%) with less than half (41.9%) of the respondents not attaining the minimum daily requirements of the fruit’s servings recommended by World Health Organization (WHO). The mean energy intake of the 172 respondents was below the ESPEN Clinical guidelines recommendations. More than half (51.7%) of the respondents were at a high risk of developing malnutrition and there was a statistically significant difference between individual energy intake and the nutrition status (P<0.05) rejecting the null hypothesis that there is no significant association between the energy intake and the risk of being malnourished. Linear regression r (0.41) showed a significant (P<0.05) weak positive association between a person’s diet intake and the malnutrition risk. The analysis shows that 16.7% of the overall risk of malnutrition can be explained by the dietary intake. Assessing the dietary practices of the cancer patients, screening them for malnutrition risk and enhancing nutrition education and counselling is key in improving therapeutic care of cancer patients. A study to reveal the knowledge and attitudes of the cancer patients towards these dietary practices would make a very significant contribution to the therapeutic care of the cancer patients.

Insights From ISASS Webinar Series on Current and Emerging Techniques in Endoscopic Spine Surgery | Part 3: A Polytomous Rasch Analysis on Surgeons' Endorsement of Multiportal Access, Treatment of Lumbar Facet Cyst, Grade I Spondylolisthesis, and Interbody Fusion.

The International Society for the Advancement of Spine Surgery hosted the third in a series of webinars focused on innovative endoscopic spine surgery techniques. This session aimed to discuss and evaluate advanced treatments for lumbar spinal stenosis and related conditions utilizing multiportal endoscopic approaches; articulating instruments; unilateral biportal endoscopy; transforaminal techniques for facet cysts, herniated disc, and spinal stenosis; as well as percutaneous endoscopic lumbar interbody fusion (PELIF). To analyze the level of surgeon endorsement for the presented endoscopic spine surgery techniques before and after the webinar, utilizing polytomous Rasch analysis, and to evaluate the potential for these insights to inform clinical guideline recommendations. An online survey was administered to 868 surgeons during a sponsored webinar hosted by the International Society for the Advancement of Spine Surgery. The survey used Likert-scale ratings to evaluate 5 main topics and additional surgical experiences and was distributed before and after the webinar. Survey responses were analyzed using descriptive statistics and Polytomous Rasch analysis to evaluate shifts in acceptance and perception. Of the 793 surgeons who attended the webinar, 229 accessed the prewebinar survey, 154 began it, and 119 completed it, yielding a completion rate of 77.3%. The respondents included 52.9% orthopedic surgeons, 37.0% neurosurgeons, 1.7% fellows, 0.8% residents, and 0.8% medical students. In the postwebinar phase, engagement remained high, with 298 accessing the survey, 169 starting it, and 128 completing it, resulting in a 75.7% completion rate. The postwebinar participant demographics closely resembled the initial distribution, consisting of 53.1% orthopedic surgeons, 35.9% neurosurgeons, 6.2% residents, 3.1% fellows, and 1.6% medical students. The confidence in various endoscopic techniques saw notable changes, particularly for procedures involving transforaminal lateral canal decompression for stenosis, herniated disc, and low-grade spondylolisthesis. Unilateral biportal endoscopy facet joint decompression and PELIF saw an increase in high-level endorsements after the webinar. Polytomous Rasch analysis provided insights into procedural techniques. The study showed consensus on the effectiveness of percutaneous endoscopic decompression of low-grade spondylolisthesis, reflecting evolving surgeon preferences and consensus on best practices. Infit and outfit statistics from the Rasch analysis suggested a good fit between the survey responses and the Rasch model both before and after the webinar, indicating minimal data distortion due to bias except for transforaminal decompression for posterolateral and central herniated nucleus pulposus. Differential item functioning analysis showed no significant bias in item responses between orthopedic surgeons and neurosurgeons in the prewebinar survey but identified potential bias for 1 item postwebinar in PELIF and articulating instruments. The webinar influenced surgeon perceptions and endorsements of advanced endoscopic techniques, substantially impacting professional practice. Continued use of Rasch analysis in evaluating educational interventions offered a nuanced understanding of changes in surgical practice toward more complex and controversial issues such as central and migrated herniated nucleus pulposus, facet cyst, low-grade spondylolisthesis, and fusion while potentially guiding future clinical guidelines and training programs to align with evolving endoscopic techniques. Assessing surgeon confidence and acceptance of endoscopic spinal surgeries using polytomous Rasch analysis. Level 2 (inferential) and 3 (observational) evidence because Rasch analysis provides statistical validation of instruments rather than direct clinical outcomes.

Key Takeaways From the ISASS Webinar Series on Current and Emerging Techniques in Endoscopic Spine Surgery | Part 2: Polytomous Rasch Analysis of Learning Curve and Surgeon Endorsement of Biportal, Interlaminar, and Transforaminal Endoscopic Stenosis Decompression, Discectomy, and Laminectomy in Combination With Interspinous Process Spacers.

The International Society for the Advancement of Spine Surgery hosted the second of a series of 4 webinars on endoscopic spine surgery techniques. The second webinar focused on the application of unilateral biportal endoscopy for discectomy and laminectomy in combination with interbody fusion and interspinous process spacers. This series was intended to identify current trends with contemporary modern endoscopic spine surgery techniques. To analyze the level of surgeon endorsement for the presented endoscopic spine surgery techniques before and after the webinar utilizing polytomous Rasch analysis, as well as to evaluate the potential for these insights to inform clinical guideline recommendations. A survey was available to 667 potential respondents during the Zoom webinar, collecting data on surgeon endorsements using a Likert scale. The polytomous Rasch model was employed to analyze responses while considering the complexity of decisions against surgeon expertise, developing a logarithmic measurement scale, allowing objective statistical analysis of categorical variables, highlighting incongruent or out of order items vs congruent and in order items, and driving improvement in clinical guidelines. Of the 667 surgeons who participated in the webinar, 224 accessed, 122 started, and 61 completed the prewebinar survey, achieving a 50.0% completion rate. Respondents comprised primarily orthopedic surgeons (70.5%) and neurosurgeons (24.6%), with fellows and medical students each making up 1.6%. These surgeons estimated that mastering the learning curve of endoscopic spine surgery required an average of 18.08 cases corroborated by postwebinar responses averaging 15.78 cases. Descriptive statistics revealed an acknowledgment of a learning curve in mastering endoscopic spine surgery, with a slight increase in recognition postwebinar (81.8% up from 80.3%). The data underscored the importance of cadaver courses and high-volume surgical practice before the webinar and highlighted the value of mentorship afterward, indicating a preference shift toward more interactive learning. The confidence in various endoscopic techniques saw notable changes, particularly for procedures involving interlaminar lateral canal decompression and the combined use of transforaminal endoscopic decompression with interspinous process spacers, which saw an increase in high-level endorsements postwebinar. Polytomous Rasch analysis provided insights into training methods and procedural techniques, with mentorship and cadaver courses emerging as key elements for mastering the learning curve. The analysis also highlighted a general consensus on the effectiveness of percutaneous endoscopic interlaminar decompression for lateral canal stenosis, reflecting evolving surgeon preferences and consensus on best practices. Infit and outfit statistics from the Rasch analysis suggested a good fit between the survey responses and the Rasch model both before and after the webinar, indicating minimal data distortion due to bias. Differential item functioning analysis showed no significant bias in item responses between orthopedic surgeons and neurosurgeons in the prewebinar survey, but it identified potential bias for one item postwebinar-unilateral biportal endoscopic laminectomy for central stenosis. This webinar highlighted the importance of hands-on training methods such as cadaver courses and mentorship in mastering the complex spinal endoscopy procedures. The application of polytomous Rasch analysis provided a detailed understanding of surgeons' current preferences and perceptions, as well as the evolving consensus on best practices in endoscopic spine surgery, displaying wide acceptance of the percutaneous interlaminar endoscopic decompression for lateral canal stenosis decompression and a growing interest in integrating endoscopic techniques for more comprehensive spinal care, including wide decompression and spinal stabilization. Assessing surgeon confidence and acceptance of endoscopic spinal surgeries using polytomous Rasch analysis. Level 2 (inferential) and 3 (observational) evidence because Rasch analysis provides statistical validation of instruments rather than direct clinical outcomes.

Key Takeaways From ISASS Webinar Series on Endoscopic Spine Surgery Techniques | Part 4: Advancing the Curve on Surgeons' Experience With Complex Lumbar Revision Scenarios, Grades 1 to 3 Spondylolytic Spondylolisthesis, Cervical Foraminotomy, and Cervical Spondylotic Myelopathy.

The fourth webinar in a 4-part series hosted by the International Society for the Advancement of Spine Surgery explored contemporary endoscopic spine surgery techniques. This session covered complex revision strategies, endoscopic management of grades 1-3 spondylolytic spondylolisthesis, cervical foraminotomy, and decompression techniques for cervical spondylotic myelopathy (CSM). The aim was to assess surgeon endorsement of the discussed endoscopic spine surgery techniques both before and after the webinar using polytomous Rasch analysis. Additionally, the analysis sought to determine how these insights might shape clinical guideline recommendations. Before the webinar, which was attended by 868 potential participants, a survey was distributed to collect data on the level of support for various techniques using a Likert scale. The polytomous Rasch model analyzed these responses by evaluating decision complexity relative to surgeon expertise. This approach helped develop a logarithmic scale to objectively analyze categorical responses, distinguish between congruent and incongruent items, and contribute to the enhancement of clinical guidelines. Of the 868 surgeons, 263 accessed, 150 started, and 118 completed the prewebinar survey, with a completion rate of 78.7%. The participants were mainly orthopedic surgeons (59.3%) and neurosurgeons (34.7%) but also included residents (2.5%), fellows (1.7%), and interventional radiologists (1.7%). In the postwebinar phase, 298 participants accessed the survey, 169 started it, and 128 completed it, achieving a 75.7% completion rate. The demographics of postwebinar participants closely mirrored the initial group: 66.4% orthopedic surgeons, 23.4% neurosurgeons, 3.6% residents, 2.9% fellows, 0.7% medical students, and 2.9% interventional radiologists. The Rasch analysis confirmed high surgeon confidence for the posterior cervical foraminotomy and endoscopic treatment of spondylolytic spondylolisthesis grades 1 to 3 and posterior endoscopic decompression for CSM. Both pre- and postwebinar responses showed a good fit to the Rasch model for these endoscopic techniques, indicating minimal bias, supported by differential item functioning analysis. The application of the endoscopic surgery platform for procedures such as lumbar revision surgery for adjacent segment disease or failed interbody fusion cages and posterior decompression of CSM saw little shift in endorsement, as evidenced both in descriptive and the logarithmically transformed Rasch statistics. This webinar highlighted the evolving consensus on best practices in endoscopic spine surgery, displaying wide acceptance of endoscopic debridement of spondylolytic spondylolisthesis, cervical foraminotomy for herniated disc and bony stenosis, and posterior endoscopic decompression for CSM. Assessing surgeon confidence and acceptance of endoscopic spinal surgeries using polytomous Rasch analysis. Level 2 (inferential) and 3 (observational) evidence because Rasch analysis provides statistical validation of instruments rather than direct clinical outcomes.

Insights From the ISASS Webinar Series on Current and Emerging Techniques in Endoscopic Spine Surgery | Part 1: Polytomous Rasch Analysis of Surgeon Endorsement of Endoscopic Discectomy/Foraminotomy, Interbody Fusion, and Importance of Patient Feedback During Surgery.

The International Society for the Advancement of Spine Surgery hosted the first of a series of 4 webinars on endoscopic spine surgery techniques, focusing on end§oscopic discectomy, foraminotomy, instrumented endoscopic fusion, standalone lumbar interbody fusion with innovative materials, and the role of patient feedback in awake procedures. This series aims to share knowledge and discuss the complexities and clinical evidence of modern endoscopic spine surgery. To analyze the level of surgeon endorsement for the presented endoscopic spine surgery techniques before and after the webinar, utilizing polytomous Rasch analysis, and to evaluate the potential for these insights to inform clinical guideline recommendations. A survey was available to 1311 potential respondents during the Zoom webinar, collecting data on surgeon endorsements using a Likert scale. The polytomous Rasch model was employed to analyze responses, considering the complexity of decisions against surgeon expertise, developing a logarithmic measurement scale, allowing objective statistical analysis of categorical variables, highlighting incongruent or out-of-order items vs congruent and in-order items, and driving improvement in clinical guidelines. All 4 topics received higher confidence ratings demonstrated by descriptive statistics, highlighting the webinar's effective role in surgeon education and in identifying ongoing trends in spine surgery. The logarithmic transformation of these data during Rasch analysis showed noticeable shifts in surgeon confidence levels postwebinar, with increased endorsement for transforaminal full-endoscopic thoracolumbar interbody fusion for hard disc herniation and standalone endoscopic lumbar interbody fusion. The Wright plot and person-item map analyses demonstrated that the webinar effectively targeted areas of initial low confidence, significantly impacting surgeons' perceptions. Disordered endorsement thresholds remained in the topics of uniportal transforaminal discectomy/foraminotomy and patient feedback during endoscopic spine surgery, indicating issues in response category discrimination or confounding factors not captured by the survey. Ongoing controversies were highlighted by the influence of confounding factors, stemming from preconceived notions and limited familiarity with high-grade evidence. The first in the 4-part webinar series effectively shifted professional confidence and acceptance of innovative surgical approaches among spine surgeons. Observations indicated a high level of interest in applying the endoscopic surgery platform with other advanced technologies. The polytomous Rasch analysis provided nuanced insights into ongoing trends and areas in need of further clarification. Assessing surgeon confidence and acceptance of endoscopic spinal surgeries using polytomous Rasch analysis. Level 2 (inferential) and 3 (observational) evidence because Rasch analysis provides statistical validation of instruments rather than direct clinical outcomes.

Postnatal care after gestational diabetes – a systematic review of clinical practice guidelines

BackgroundGestational diabetes mellitus (GDM) is the most common metabolic disorder in pregnancy and later is associated with an increased risk of type 2 diabetes and other metabolic disorders. Consistent and evidence based postnatal care is key to improving maternal long-term health. We therefore aimed to review and compare recommendations of national and international clinical practice guidelines (CPG) for postnatal care after GDM and identify any evidence gaps in recommendations needing further research.MethodsWe searched five databases and forty professional organization websites for CPGs providing recommendations for postnatal care after GDM. CPGs which had full versions in English, endorsed, prepared, or authorized by a professional body, and published between 2013 and 2023 were eligible for inclusion. Two reviewers independently screened the articles, extracted the recommendations, and appraised the included CPGs using the Appraisal of Guidelines, Research, and Evaluation (AGREE) II tool.ResultsTwenty-six CPGs from 22 countries were included. Twelve CPGs (46%) were appraised as low quality with the lowest scoring domains being rigor of development and editorial independence. We found little high certainty evidence for most recommendations and few recommendations were made for maternal mental health and postpartum metabolic screening. Evidence gaps pertained to postpartum glucose screening, including frequency, tests, and ways to improve uptake, evaluation of effective uptake of lifestyle interventions, and ongoing long-term follow up care.ConclusionsMost of the postnatal care recommendations in GDM guidelines are not based on high certainty evidence. Further efforts are needed to improve the global evidence base for postnatal care after GDM to improve long-term maternal health.Protocol RegistrationThis review was registered in PROSEPRO (CRD42023454900).

Evaluating the Importance of Practice-Level Factors on Adherence to Prostate Cancer Treatment Guidelines in Urology

ObjectiveTo evaluate adherence to treatment guideline recommendations across the continuum of prostate cancer care by US community urologists using several prostate cancer (PCa) specific performance indicators (PIs). Additionally, to determine which practice-related factors, such as having a designated PCa patient champion, active patient management in a patient portal, and in-office dispensing of medications, were associated with improved PI performance. MethodsElectronic medical record data was collected retrospectively from the PPS Analytics Patient Population Health Management Platform. The cohort consisted of adult patients with a PCa-related service visit during the period 7/1/2019 to 6/30/2022. Five PIs were reviewed: dual-energy x-ray absorptiometry (DEXA) scanning with androgen deprivation therapy (ADT), systemic therapy in metastatic PCa, external beam radiation therapy (EBRT) concurrent with ADT, image monitoring, and regular testosterone testing and monitoring. ResultsA total of 101,186 patients were identified from 95 urology practices. PI adherence rates ranged from a low of 13.6% for a DEXA scan within 6-months of ADT initiation to a high of 72.3% for EBRT concurrent with ADT in intermediate/high risk localized PCa. The results also demonstrated that several practice-related features were associated with better PI adherence. ConclusionsThe findings suggest there exists a wide range in PI adherence rates for urologists in the delivery of community urology care in the Unites States compared to clinical guideline recommendations. Future research should examine the factors associated with PI nonadherence and promote implementation of interventions that enhance guideline concordant care.

Non-Invasive Therapeutic Approaches for Mechanical Low Back Pain: An Integrative Systematic Review

Background: Mechanical low back pain (LBP) is one of the most prevalent musculoskeletal conditions, affecting a significant portion of the global population at some point in their lives. It is characterized by pain in the lumbar region without an obvious inflammatory or infectious origin, typically exacerbated by movement, posture, or mechanical load. LBP, whether acute, subacute, or chronic, is a leading cause of temporary and permanent disability, with significant economic repercussions due to lost workdays and healthcare costs. Recent clinical guidelines, such as those from the American College of Physicians (ACP) and the National Institute for Health and Care Excellence (NICE), emphasize the importance of non-invasive interventions for managing mechanical LBP, particularly in acute and chronic cases. In this context, this systematic review aims to consolidate current evidence on available therapeutic interventions, focusing on non-invasive treatments. Objective: To evaluate the available evidence on non-invasive therapeutic interventions for the treatment of mechanical low back pain. The review aims to synthesize international clinical guideline recommendations and identify the most effective practices for reducing pain and improving functional outcomes. Methods: This review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Randomized controlled trials, systematic reviews, and clinical guidelines published up to 2023 addressing the management of mechanical low back pain in adults were included. Databases such as PubMed, Cochrane Library, and grey literature sources, including guidelines from medical societies, were searched. The study selection process followed strict eligibility criteria, including publications in English and Portuguese focused on non-invasive treatments for LBP. The methodological quality of the studies was assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) tool. A total of 15 studies met the inclusion criteria, covering a range of non-invasive interventions such as physical therapy, exercise, acupuncture, manual therapy, and pharmacological approaches. Results: Evidence suggests that exercise-based interventions, particularly programs focused on muscle strengthening and stretching, are effective in reducing pain and improving functional outcomes in patients with mechanical LBP. Manual therapies and acupuncture also demonstrated benefits, albeit with less robust evidence. Reviewed guidelines recommend caution in the use of pharmacological interventions, such as nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in chronic cases. Conclusion: This review highlights that non-invasive therapies, especially supervised exercise programs, represent the most effective and safe treatment for mechanical low back pain. The revised international guidelines reinforce the importance of avoiding early invasive interventions, except in cases of persistent or refractory pain. Appropriate management of mechanical LBP should be individualized, integrating evidence-based interventions to promote functional rehabilitation and minimize the impact of pain on patients' quality of life.

Falsas creencias en torno al dolor. Consejos educativos breves en la consulta de atención primaria

In chronic non-oncological pain, there is a gap between the recommendations and the usual clinical practice. To improve this situation, it is essential to address unhelpful beliefs about pain in patients and health professionals. We address cultural beliefs such as thinking that pain means damage to the tissue where it is felt, that pain originates in the area where it is perceived, that it is important to rest for the tissues to heal, or that drugs and surgery are the best treatments for pain.First, professionals need to reflect on their own beliefs and question their own clinical practice: what do I believe about pain? Are these beliefs in line with current evidence? Do I follow the recommendations of clinical practice guidelines? In this way, by aligning their beliefs with the evidence, professionals will be able to begin to give appropriate educational advice to patients.

Patterns of Amphotericin B Use and Factors Related to Mortality in a Low-Middle Income Country: An Observational and Longitudinal Study.

Background/Objectives: Amphotericin B is indicated in deep systemic fungal infections. The aim was to determine the sociodemographic, clinical and pharmacological variables of a group of Colombian patients treated with amphotericin B and factors associated with mo rtality. Methods: A longitudinal observational retrospective study on the use of amphotericin B in Colombia was conducted between January 2015 and December 2022. The multivariate analysis sought to identify variables related to mortality. Results: A total of 310 patients were identified, with a median age of 44.0 years, and 71.0% were women. Conventional amphotericin B was the most used (74.8%). The main uses were cryptococcosis (38.7%), histoplasmosis (31.9%) and candidiasis (29.4%). More than a third of patients died during hospitalization (40.3%). An increase in the Charlson Comorbidity Index score (HR: 1.13; 95% CI: 1.05-1.22) and in the qSOFA score (HR: 1.34; 95% CI: 1.04-1.73), coinfection by Mycobacterium tuberculosis (HR: 2.09; 95% CI: 1.32-3.31) and the requirement of vasopressors (HR: 4.20; 95% CI: 2.16-8.15) or invasive mechanical ventilation (HR: 2.73; 95% CI: 1.40-5.33) increased the probability of in-hospital death. In contrast, those who received systemic corticosteroids (HR: 0.43; 95% CI: 0.26-0.70) had a lower risk. Conventional amphotericin B is the most used drug mainly treating Cryptococcus neoformans infections. Conclusions: The use of amphotericin B was consistent with clinical practice guideline recommendations. In-hospital mortality was common, and factors such as increased comorbidities, higher qSOFA scores, coinfection with Mycobacterium tuberculosis and invasive procedures like mechanical ventilation were linked to increased mortality.

Time taken for cardiology care and one-year results for primary care physicians' referrals for cardiology consultation in heart failure patients: clinical implications for heart failure management

Abstract Background and Purpose The clinical trajectory of patients with heart failure (HF) is characterised by frequent episodes of decompensation requiring urgent medical assistance, hospitalisations, and an increased risk of mortality. HF clinical guidelines recommend early visits by health professionals after hospital discharge, yet little evidence exists regarding the associations between delayed medical attention and outcomes in HF patients. To assess the clinical impact of the time taken to receive cardiology care for referrals from primary care physicians (PCPs) to a cardiology department in HF patients, we selected 6,859 HF patients who visited the cardiology service at least once between 2010 and 2021. Methods Using an interrupted time series regression model, we analysed the impact of integrating e-consultations into the healthcare model (implemented in 2013) and evaluated the time taken to receive cardiology care, as well as all-cause, cardiovascular (CV), and HF-related hospital admissions and mortality. The primary objective of this analysis was to examine the associations between delays in cardiology care following a PCP referral and 1-year outcomes (HF-related, cardiovascular, and total hospitalisations; and HF-related, cardiovascular, and total mortality). Results Almost 50% were women, and the mean age was 77.8 years. Arterial hypertension (79.6%), diabetes (34%), atrial fibrillation (51.4%), ischemic heart disease (20.4%), and cerebrovascular disease were the most prevalent comorbidities. The mean time from PCP referral to cardiology consultation in the overall population was 22.3 days: <8 days in 53.9%, 8-14 days in 17.1%, 15-30 days in 15.9%, and >30 days in 13.0% of patients, respectively. One year after cardiology consultation, 68.6% of patients required assistance in an Emergency Department; 22.5% were hospitalised for any cause, 14.9% for cardiovascular reasons, and 9.2% for HF-related issues. Moreover, total mortality at 1-year was 8.6%, comprising 4.3% cardiovascular mortality and 1.3% HF-related deaths. Multivariate analysis of the relationship between the time taken to receive cardiology care and 1-year outcomes revealed a significant increased risk associated with a longer delay in cardiology assistance, particularly evident in the subgroup of patients with previous hospital admissions due to worsening HF (see Table). Conclusions Throughout the follow-up period, a reduced time taken to receive care was independently associated with better 1-year outcomes. We believe that our experience can contribute to the development of a more efficient ambulatory care pathway for HF patients, especially those at high risk, such as those with a history of hospitalisation due to worsening events. Our findings further support the clinical guideline recommendation for early contact by health professionals following hospital discharge, extending it to include PCP referrals for cardiology consultations.

Reassessing pharmacological trials with positive composite outcome driven by reduction in nonfatal myocardial infarction: a systematic review and meta-analysis

Abstract Background Nonfatal myocardial infarction (MI) inadequately predicts cardiovascular and all-cause mortality in contemporary RCTs. The perceived efficacy of new treatments could be overstated if positivity in composite outcome is primarily attributed to reduction in nonfatal MI. Purpose This study seeks to assess pharmacological RCTs with positive results influenced by nonfatal MI reductions and scrutinize the associated clinical guideline recommendations. Methods Pharmacological RCTs focusing on mortality and nonfatal MI published from 2000 to 2023 were searched in PubMed and Web of Science, with subsequent citation tracking in Web of Science and Google Scholar for candidate RCTs referenced in English-language clinical guidelines. Main outcomes included: 1) relative risk reduction in the composite outcome excluding nonfatal MI; 2) relevant guideline recommendations based on the supporting trials. The impact of nonfatal MI on composite outcome was assessed by using the leave-one-out method. Meta-analysis utilized a random effects model. Results After reviewing 19,825 records, we identified 8 RCTs where positive composite outcomes were driven by reductions in non-fatal MI (Figure 1A). These were divided into three therapeutic groups: anti-thrombotic (3 trials), lipid-lowering (3 trials), and anti-inflammatory (2 trials). In guidelines citing these RCTs, lipid-lowering trials (IMPROVE-IT, FOURIER, CLEAR Outcomes; the latter has not been cited yet; a total of 60 recommendations across 17 guidelines; Figure 2) outperformed anti-thrombotic (27 recommendations across 15 guidelines) and anti-inflammatory trials (3 recommendations in 3 guidelines), with significantly higher Class I (45%) and IIa (33.3%) recommendations, and fewer Class IIb (21.7%) recommendations, compared to anti-thrombotic (0%, 22.2%, 66.7%) and anti-inflammatory (0%, 0%, 100%) trials (Figure 1B). In a meta-analysis of all trials on combined intensive lipid-lowering on top of maximally-tolerated statins (the ODYSSEY OUTCOMES, IMPROVE-IT, and FOURIER trials), the exclusion of nonfatal MI data sustained the negative findings (HR 0.94, 95% CI: 0.88 to 1.01). Conclusions Despite the overestimation of efficacy in certain anti-thrombotic, anti-inflammatory, and lipid-lowering RCTs due to the inclusion of nonfatal MI, lipid-lowering trials, particularly those supporting combined intensive therapy with statins, still receive disproportionately favorable guideline recommendations. This underscores the need to reassess the strength of evidence for these trials in guidelines, advocating for a more equitable and evidence-based approach to cardiovascular guideline recommendations.

Breast cancer diagnosis and staging in Chile: A non-randomized survey-based study to assess frequency and delays.

Breast cancer progression involves physiological mechanisms such as metastasis. Delays in diagnosis and treatment increase the risk of mortality and are associated with barriers to healthcare access. In Chile, breast cancer is highly prevalent, and early diagnosis has improved, although disparities in the disease evolution persist. This study characterized diagnostic and staging tests, waiting times, and sociodemographic profiles to identify delays and inequities in care. Survey study. Using a non-probabilistic sample, a questionnaire was applied in an encrypted platform with prior informed consent. The instrument collected data on requested tests, associated times, staging, and sociodemographic characteristics. These variables were analyzed using descriptive statistics, tests of association, confidence intervals, and comparison tests using bootstrapping. A sample of 263 persons was obtained. The most requested tests were biopsy (99.62%) and blood tests (80.23%). The median number of tests requested was six (Q1:4, Q3:8), with a mean of 5.87 (standard deviation: 2.24). No significant differences were observed in the percentage of persons from whom the total number of examinations were requested according to the studied variables. The day-hour-result intervals ranged from 1 to 365 days. The median day-hour-result of the biopsy was 15 days (Q1:10, Q3:30). People between 40 and 49 years old, non-residents of the capital city, belonging to income quintile I, with high school education, from the public health system, with late-stage diagnosis had higher median day-hour-result in biopsy. There was no significant difference in the number of requested tests according to staging (I and II, or III and IV). Biopsy in Chile is the test of choice for diagnostic confirmation in breast cancer. Other tests are requested regardless of the diagnosis stage, contrary to the recommendations of clinical guidelines. Cancer prognosis is crucial, especially in countries with greater inequalities.

Assessment of the quality and content of clinical practice guidelines for vitamin D and for immigrants using the AGREE II instrument: global systematic review

BackgroundWorldwide, more immigrants experience vitamin D (vitD) deficiency than non-immigrants. Recommendations in current clinical practice guidelines (CPGs) concerning vitD are inadequate to address vitD deficiency among immigrants, and there are...

Cost-effectiveness of a novel AI technology to quantify coronary inflammation and cardiovascular risk in patients undergoing routine Coronary Computed Tomography Angiography.

Coronary Computed Tomography Angiography (CCTA) is a first line investigation for chest pain in patients with suspected obstructive coronary artery disease (CAD). However, many acute cardiac events occur in the absence of obstructive CAD. We assessed the lifetime cost-effectiveness of integrating a novel artificial intelligence-enhanced image analysis algorithm (AI-Risk) that stratifies the risk of cardiac events by quantifying coronary inflammation, combined with the extent of coronary artery plaque and clinical risk factors, by analysing images from routine CCTA. A hybrid decision-tree with population cohort Markov model was developed from 3,393 consecutive patients who underwent routine CCTA for suspected obstructive CAD and followed up for major adverse cardiac events over a median(IQR) of 7.7(6.4-9.1) years. In a prospective real-world evaluation survey of 744 consecutive patients undergoing CCTA for chest pain investigation, the availability of AI-Risk assessment led to treatment initiation or intensification in 45% of patients. In a further prospective study of 1,214 consecutive patients with extensive guideline recommended cardiovascular risk profiling, AI-Risk stratification led to treatment initiation or intensification in 39% of patients beyond the current clinical guideline recommendations. Treatment guided by AI-Risk modelled over a lifetime horizon could lead to fewer cardiac events (relative reductions of 4%, 4%, 11%, and 12% for myocardial infarction, ischaemic stroke, heart failure and cardiac death, respectively). Implementing AI-Risk classification in routine interpretation of CCTA is highly likely to be cost-effective (Incremental cost-effectiveness ratio £1,371-3,244), both in scenarios of current guideline compliance or when applied only to patients without obstructive CAD. Compared with standard care, the addition of AI-Risk assessment in routine CCTA interpretation is cost effective, by refining risk guided medical management.

Chiropractic and Spinal Manipulation: A Review of Research Trends, Evidence Gaps, and Guideline Recommendations

Chiropractors diagnose and manage musculoskeletal disorders, commonly using spinal manipulative therapy (SMT). Over the past half-century, the chiropractic profession has seen increased utilization in the United States following Medicare authorization for payment of chiropractic SMT in 1972. We reviewed chiropractic research trends since that year and recent clinical practice guideline (CPG) recommendations regarding SMT. We searched Scopus for articles associated with chiropractic (spanning 1972–2024), analyzing publication trends and keywords, and searched PubMed, Scopus, and Web of Science for CPGs addressing SMT use (spanning 2013–2024). We identified 6286 articles on chiropractic. The rate of publication trended upward. Keywords initially related to historical evolution, scope of practice, medicolegal, and regulatory aspects evolved to include randomized controlled trials and systematic reviews. We identified 33 CPGs, providing a total of 59 SMT-related recommendations. The recommendations primarily targeted low back pain (n = 21) and neck pain (n = 14); of these, 90% favored SMT for low back pain while 100% favored SMT for neck pain. Recent CPG recommendations favored SMT for tension-type and cervicogenic headaches. There has been substantial growth in the number and quality of chiropractic research articles over the past 50 years, resulting in multiple CPG recommendations favoring SMT. These findings reinforce the utility of SMT for spine-related disorders.

Description of Medical and Surgical Conditions Requiring Referral by Physical Therapy Providers in Primary Contact Musculoskeletal Practice

OBJECTIVE: The Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association's clinical practice guideline recommendations provide a foundation for clinicians' musculoskeletal care. Some patients’ presenting clinical findings suggest conditions that would benefit from medical or surgical evaluation and management. Guidelines are not available that direct this referral. DESIGN: This practice description directs the development of guidelines for clinicians working as first provider musculoskeletal practitioners on the diagnostic criteria for referring clients for medical or surgical management. METHODS: The foundational step in developing these guidelines is to identify the conditions that first provider musculoskeletal practitioners are likely to encounter during clinical practice. This study used standard practice analysis methodology to identify and describe these conditions. RESULTS/CONCLUSION: The ensuing clinical practice guideline, based on systematic methods to evaluate and classify evidence, will provide graded recommendations on the criteria to identify, level of confidence with identifying, and urgency for referring patients, with the conditions described in this practice analysis, for medical and surgical evaluation and management.