Scottish Intercollegiate Guidelines Network Research Articles

PP121 Assessment Of Heart Rate Characteristics Analysis

IntroductionThe heart rate characteristics (HRC) analysis is a technique for predicting and monitoring neonatal infectious diseases in infants with a risk for infectious disease, such as sepsis, using the HRC index based on the electrocardiogram (ECG) data transmitted from a HeRO® device connected to an ECG monitor.MethodsThe assessments were performed via a systematic review. Searching five databases (KoreaMed, Ovid-MEDLINE, Ovid-EMBASE, and Cochrane) yielded 284 related studies. Two reviewers independently assessed the quality of these studies, using the Scottish Intercollegiate Guidelines Network checklist and the assessment results were described based on the results of the quality appraisal and level of evidence.ResultsThe safety and effectiveness of the technique were assessed based on eight non-Korean studies (one randomized controlled trial (RCT), five cohort studies, one case-control study, one case series). The four studies that reported area under the curve (AUC) values, the timing of the analysis and AUC values (0.67– 0.75) were inconsistent among the studies. The elevation of the HRC index prior to the diagnosis of an infectious disease was not observed for meningitis or for multiple infectious diseases. In addition, although the group with additional monitoring using the technique had a significantly lower mortality rate, whether the HRC index had a direct impact on the infection prevention activities and the possibility of bias arising from the researchers’ precautionary treatment based on the clinical symptoms and other test results as well as the actual time of disease onset are unknown.ConclusionsTherefore, the committee presented the following recommendations based on the available evidence and expert opinion. HRC analysis is a safe technique for predicting and monitoring neonatal infectious diseases in infants with a risk for infectious disease, such as sepsis, using the HRC index based on the ECG data transmitted from a HeRO® device connected to an ECG monitor; however, further research is needed to determine its effectiveness (Level of evidence C, Technology category II-a).

Adherence to National Asthma Guidelines in the Acute Care Setting: A Retrospective Cohort Study.

Peak flow is a crucial but simple test used to categorize the severity of an episode of an acute exacerbation of asthma.It should be regularly done in all the patients who present with asthma acute exacerbation in the emergency department. The British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) guidelines stipulate peak flow use as one of the main tools to categorize acute asthma into moderate, severe, and life-threatening asthma. The BTS and SIGN guidelines also state peak flow is to be utilized in monitoring the disease and to guide in treating patients with acute asthma. This study aims to identify the adherence to BTS/SIGN guidelines around the use of peak expiratory flow rate (PEFR) in assessing the severity of patients presenting with acute exacerbation of asthma in a district general hospital. The retrospective cohort study involved collating data between October 2022 and February 2023 from our hospital electronic system. The data collected about the use of PEFR and whether the patients were being classified by severity in presentation following this was compared to the BTS/SIGN 158 asthma guidelines. Following this, the data analysis was done using IBM SPSS Statistics for Windows, Version 21.0 (Released 2012; IBM Corp., Armonk, New York, United States). Data from 92 patients were collated. PEFR was recorded for 29.3% (n=27) of patients and acute exacerbation of asthma severity was documented in merely 17.4% (n=16) patients. The results indicate a significant proportion of the patient cohort analyzed did not have peak flow readings, there is clear room for improvement, and further intervention is needed in order for the department to adhere to the gold standard guidelines (i.e., BTS/SIGN 158), and thus improve the management and monitoring of acute asthma exacerbations. Future directions can include departmental education, posters as a reminder, and prompts on the electronic system used to alert users to check PEFR when a diagnosis of acute asthma exacerbation is documented.

Assessment of off-label prescribing: profile, evidence and evolution

ObjectiveThe objectives of the study were to describe the extent and profile of off-label prescriptions, to evaluate the level of evidence supporting these indications, to assess the research activity in these conditions, and to determine to what extent these were authorized as new indications five years after the application. MethodsA cross-sectional study including all applications conducted in the Hospital Universitario Reina Sofía in Córdoba during 2010. Analysis: level of evidence according to the criteria by SIGN-NICE (Scottish Intercollegiate Guidelines Network, National Institute for Health and Care Excellence) and CEBM (Centre for Evidence-based Medicine), registered clinical trials (source: ClinicalTrials.gov), and review of product specifications and monthly newsletters from the Spanish Agency of Medicines and Medical Devices. ResultsThere were 190 applications for off-label prescription for 82 different indications. The most requested medications were: tacrolimus, mycophenolate, colistimethate and everolimus; the immunosuppressant group had the highest number of uses for non-approved indications. Out of the applications, 52.4% were based on some clinical trial, while the rest had a low level of evidence (observational studies and case reports). We have found on-going clinical trials for 67% of the indications, but new indications in their product specifications have only been authorized for nine drugs (bevacizumab, deferasirox, everolimus, lenalidomide, methotrexate, sildenafil, sorafenib, raltegravir and tenofovir). ConclusionsWe have detected a major volume of off-label prescription without good supporting evidence, which identifies these indications and medications as interesting research lines, but that require follow-up in terms of effectiveness and costs.

Advice following a possible first seizure: what do patients attending for EEG remember?

PurposeThis study was designed to assess the knowledge of patients following their first seizure or blackout of unknown cause. We aimed to compare the advice our cohort of patients recalled against that suggested in the current literature. Background5 % of the population will experience a non- febrile seizure in their lifetime. Education and advice for the patient and their family is an important aspect of their care. MethodAfter reviewing the recommended guidelines from both the Scottish Intercollegiate Guidelines Network and the National Institute for Health and Care Excellence, a questionnaire was developed. From 1st May 2020 to 1st September 2022, a questionnaire was given to eligible patients attending St. James's Hospital for an electroencephalogram (EEG) following their first possible seizure or blackout of unknown cause. The patients were provided with a list of topics and were asked to select which, if any, were discussed with them. ResultsA total of 50 eligible adults participated in the study. Driving was the topic most frequently recalled as having been discussed at 66 % followed by family education. ConclusionIt has been recognised that patients remember as little as a fifth of information initially discussed, failing to recall 40–80 % of content within medical encounters and our study supports this. This highlights the need to review the information delivered and how this is achieved as well as using new methods to help increase the retention of this vital information.

Summary of best evidence for self-management in postoperative osteoporotic fracture patients

Osteoporotic fracture as a serious complication of osteoporosis which is usually treated surgically, and its recovery is closely related to one's own behavior and lifestyle, and is a long-term, complex management process that often requires the individual to self-manage many health-related factors. ObjectiveTo gather and synthesize the most robust evidence regarding self-management in patients with postoperative osteoporotic fractures, in order to provide scientific, evidence-based guidance for clinical healthcare professionals to assist postoperative patients in self-management efforts, and to assist patients in optimizing their self-management practices and behavioral norms. MethodsBased on the “6 S” pyramid model of evidence resources (System, Summaries, Synopses of synthesis, Syntheses, Synopses of studies, Studies), we searched the Up To Date, BMJ Best Practice, The Cochrane Library, Australian Joanna Briggs Institute JBI Evidence-Based Medicine Center Healthcare Database, National Institute for Health and Clinical Excellence (NICE), Guidelines International Network (GIN), National Guideline Clearinghouse (NGC) and Scottish Intercollegiate Guide lines Network (SIGN), MedPulse, Embase, PubMed, CINAHL, Web of Science, SinoMed, Chinese Medical Journal Full Text Database, CNKI, Wanfang Data Knowledge Service Platform, and VIP database, etc, The search period for clinical decision-making, systematic evaluation, clinical guidelines, evidence summaries and expert consensus on self-management of postoperative osteoporotic fracture patients, and it was from the establishment of the database to 18 February 2023. To ensure the quality of the literature, three researchers strictly screened the literature according to the literature inclusion and exclusion criteria, and two or more researchers independently evaluated the quality of the included literature, and extracted and integrated the relevant evidence. ResultsThirteen documents were finally included, including 4 clinical practice guidelines, 5 expert consensus, 2 recommended practices, 1 systematic evaluation, and 1 clinical decision report. The research team summarized the evidence in 6 dimensions: multidisciplinary teamwork, management of daily living, management of treatment adherence, management of exercise, management of fall prevention and subsequent fracture, and management of emotions, and 33 pieces of evidence were extracted. ConclusionThe study summarized 33 best evidence of self-management in postoperative osteoporotic fracture patients, which provides a scientific and reasonable self-management program for postoperative patients, and also provides important reference and information for clinical healthcare professionals to provide more comprehensive and scientific self-management health education to patients.

Spanish consensus on the management of chronic rhinosinusitis with nasal polyps (POLIposis NAsal / POLINA 2.0).

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a high prevalent and burdensome disease for individuals and health systems which management involves many specialties: otorhinolaryngology, allergology, pulmonology, primary care, pharmacy, and paediatrics. A multidisciplinary approach and the participation of the patient in decision making are essential, both for the diagnosis and for the therapeutic strategy. The authors of the consensus aim to translate the current knowledge into an easy-to-read practical guide and emphasize those aspects in which there is still discussion or unmet needs due to the lack of proper scientific evidence. An iterative approach for the development of an evidence-based systematic review with recommendations was used, using a standard quality assessment scheme (Scottish Intercollegiate Guidelines Network -SIGN- and National Institute for Health and Care Excellence -NICE-), and a critical evaluation of the guideline has been carried out through the instrument Appraisal of Guidelines for Research and Evaluation (AGREE II) and Recommendation Excellence (AGREE REX). Based on the foregoing, the POLINA has been considered a guideline of good quality by an independent agency. The POLINA consensus contributes with new schemes for the definition of control, therapeutic management including severity evaluation and surgery, and indications for biologic use and response. Finally, this guideline focuses on the research unmet needs in CRSwNP.

Suppression of sweet taste-related responses by plant-derived bioactive compounds and eating. Part II: A systematic review in animals

This article, the second in a two-part series, continues the discussion on the nature of the relationship between the level of sweet taste suppression and eating behaviour, but in animal rather human subjects. In particular, the aim was to review the scientific literature on the impact that bioactive compounds that decrease oral sweet sensations have on intake, preference and physiological status in preclinical studies. This review was registered in the International Prospective Register of Systematic Reviews and conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Scottish Intercollegiate Guidelines Network and covered original papers included in Web of Science, PubMed, Scopus, Food Science Source and Food Science and technology abstracts. We identified 28 peer-reviewed English-language studies that fit the topic and met the inclusion criteria. We identified three plant species, Gymnema sylvestre, Hovenia dulcis, and Ziziphus jujuba, that possess acute sweetness-inhibitory properties. When administered orally, these plants reduced neural responses to sweet stimuli and decreased consumption. However, studies on the longer-term effects of antisweet activity remain to be conducted. Translating the valuable insights into the mechanisms underlying the relationship between sweet taste impairment and eating behaviour into practical clinical applications are discussed.

Suppression of sweet taste-related responses by plant-derived bioactive compounds and eating. Part I: A systematic review in humans

The taste of food plays a crucial role in determining what and how much we eat. Thus, interventions that temporarily block sweet taste receptors offer a promising approach to addressing unhealthy behaviours associated with sugary foods. However, the relationship between reduced sweet taste response and food consumption remains unclear, with contradictory findings. Certain studies suggest that a diminished perception of sweetness leads to a sense of fullness and results in reduced food intake, while others suggest the opposite effect. To shed some light, our systematic review looked into the relationship between diminished sweet taste response and food consumption by examining the effects of bioactive compounds that experimentally inhibit sweetness in healthy individuals. This review was registered in the International Prospective Register of Systematic Reviews and conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Scottish Intercollegiate Guidelines Network, and covered original papers included in Web of Science, PubMed, Scopus, Food Science Source and Food Science and technology abstracts. We identified 33 peer-reviewed English-language studies that fit the topic and met the inclusion criteria. The current literature predominantly focuses on the immediate impact of oral gymnemic acids, failing to provide preliminary evidence in support of the specific threshold hypothesis, above which food consumption decreases and below which the opposite effect occurs. Additionally, there was inconsistency in the findings regarding the short-term desire to eat following sweetness inhibition. Considering the downstream effects on energy intake and their clinical applications, further research is needed to clarify both the acute within-session effects (i.e., not wanting any more now) and the longer-term effects (i.e., deciding not to start eating) linked to oral sweet-taste-suppressing compounds.

Child maltreatment: qualitative review of theoretical and methodological trends in intervention programs with an attachment perspective

This review provides a qualitative comparative analysis of theoretical and methodological aspects of 27 studies in which the results of the implementation of programs involved in child maltreatment are presented with an attachment perspective. The studies were examined following the Scottish Intercollegiate Guidelines Network. It was found that the programs promote the development of maternal sensitivity, mentalization or reflective functioning and empathy, however, the underlying mechanisms are not differentiated according to the type of abuse to intervene. Likewise, it was found that despite the recognition of the mother's violent childhood experiences as one of the main predisposing factors for child abuse, it is a variable that is scarcely considered in the programs examined. These findings indicate the importance of developing intervention programs that consider a cumulative ecological risk perspective

184 Paying attention to the feasibility of daily delirium screening in an acute hospital setting

Abstract Background Delirium is highly prevalent, yet two-thirds of cases remain undetected. Irish national guidance recommends daily delirium screening for all acute hospital in-patients at risk of delirium, including older patients. We conducted a series of stakeholder workshops to identify the screening tool considered most feasible for daily delirium screening by staff nurses in our hospital. Methods We identified four tools validated for daily delirium screening from the Scottish Intercollegiate Guidelines Network guidelines on ‘Risk Reduction and Management of Delirium’. These included the DOS-13 (Delirium Observation Screening Scale); RADAR (Recognising Acute Delirium As part of your Routine); mRASS (modified Richmond Agitation Screening Scale); and SQiD (Single Question in Delirium). Two workshops for local nursing delirium champions were held to discuss the feasibility of each of these instruments. Workshops commenced with teaching on delirium prevention, management and the rationale for daily screening. Factors relating to the time taken to conduct the assessment, training required, suitability for nursing staff use, diagnostic accuracy, and other issues relating to feasibility were explored. Results The RADAR was considered the instrument with the best balance between feasibility of implementation and diagnostic accuracy. The mRASS was preferred as the next best option, however there was concern that this instrument would require significantly more training. The DOS-13 was considered too time-consuming and too detailed, however it was proposed as a useful behavioural charting tool in patients with known delirium. Although the SQiD was considered the quickest test to conduct, it was felt that staff changeover would lead to reduced diagnostic accuracy. Conclusion RADAR was deemed the test of choice for daily delirium assessment in UHW acute wards. A delirium care bundle incorporating the RADAR was hence developed and training of staff has commenced. The next steps will be to evaluate its feasibility and efficacy in the real-world setting.

1193 Review of Pre-Operative Antibiotic Prophylaxis (POAP) in National Emergency Laparotomy Audit (NELA) Patients in a Regional Acute Tertiary Hospital

Abstract Aim The current World Health Organization recommendation for timing before incision (TBI) is that one dose of intravenous pre-operative antibiotic prophylaxis (POAP) should be given on starting anaesthesia, within 120 minutes, to reduce surgical site infections. The Scottish Intercollegiate Guidelines Network suggests TBI of 30-60 minutes for full dosage administration. The aim was to review POAP, including TBI, in NELA patients. Method Emergency laparotomy patients were identified on the Trust theatre system over 73 days, and the NELA database reviewed. Data was collected retrospectively through anaesthetic and operation records and if still inpatient, drug charts and clinical notes. Results 46 patients were identified, and 83% had documented POAP (53% on anaesthetic record, 31% on operation note and 16% before surgery). Of these patients who had a documented POAP, 68% had a recorded TBI; mean time was 99 minutes (range 19 to 386). Of the patients who had a recorded TBI, 77% received POAP within 120 minutes; mean time of these was 59 minutes (range 19 to 112). Conclusions The majority of patients received pre-operative antibiotic prophylaxis, although the documentation was variable, and many doses were not given in the optimal time before incision to reduce surgical site infections. Further work includes liaising with the multidisciplinary team to raise awareness of these results and amending the clerking proforma. A further subgroup analysis focusing on septic patients is underway, as well as a long-term review looking into surgical site infection rates.

Anticholinergic medications associated with falls and frailty in people with HIV.

Anticholinergic medications (ACMs) are associated with poorer age-related outcomes, including falls and frailty. We investigate associations between ACM use and recurrent falls and frailty among older (aged ≥50 years) people with HIV in the POPPY study. Anticholinergic potential of co-medications at study entry was coded using the anticholinergic burden score, anticholinergic risk score, and Scottish Intercollegiate Guidelines Network score; drugs scoring ≥1 on any scale were defined as ACM. Associations with recurrent falls (two or more falls in the previous 28 days) and frailty (modified Fried's) were assessed using logistic regression adjusting for (1) possible demographic/lifestyle confounders and (2) clinical factors and depressive symptoms (Patient Health Questionnaire-9). ACM use was reported by 193 (28%) of 699 participants, with 64 (9%) receiving two or more ACM; commonly prescribed ACMs were codeine (12%), citalopram (12%), loperamide (9%), and amitriptyline (7%). Falls were reported in 63/673 (9%), and 126/609 (21%) met the frailty criteria. Both recurrent falls and frailty were more common in ACM users than in non-users (recurrent falls: 17% in users vs. 6% in non-users, p < 0.001; frailty: 32% vs. 17%, respectively, p < 0.001). Use of two or more ACMs was associated with increased odds of falls after adjustment for demographic/lifestyle factors (odds ratio [OR] 4.53; 95% confidence interval [CI] 2.06-9.98) and for clinical factors (OR 3.58; 95% CI 1.37-9.38). Similar albeit weaker associations were seen with frailty (OR 2.26; 95% CI 1.09-4.70 and OR 2.12; 95% CI 0.89-5.0, respectively). ACM are commonly prescribed for people living with HIV, and evidence exists for an association with recurrent falls and frailty. Clinicians should be alert to this and reduce ACM exposure where possible.

Withholding of Hormone Replacement Therapy Prior to Total Joint Arthroplasty Surgery to Reduce the Risk of Postoperative Thromboembolic Events: Is It Justified?—A Systematic Review of Clinical Practice Guidelines

BackgroundHormone replacement therapy (HRT), menopausal hormone therapy (MHT), and estrogen-containing medications are frequently withheld before elective lower limb arthroplasty, based on a perceived risk of venous thromboembolism (VTE). However, evidence linking HRT, MHT, and an increased VTE risk is equivocal. This systematic review evaluated the concordance of international clinical practice guidelines (CPGs) on the withholding of HRT or MHT. MethodsThe PubMed, Google Scholar, Cochrane, and Ovid databases were searched for CPGs for the preoperative, perioperative, and postoperative management of patients on HRT and MHT undergoing elective lower limb arthroplasty. This was supplemented by an internet search. There were 7 international CPGs in English, from Europe and North America, published between January 2000 and February 2023 reviewed against the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE-II) criteria, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. ResultsThe guidelines reviewed revealed a mixed picture on HRT or MHT withdrawal and use in arthroplasty, with some featuring detailed advice on the preoperative and postoperative management of HRT or MHT (Scottish Intercollegiate Guidelines Network), while others featured no guidance (American College of Chest Physicians). The evidence referenced in these guidelines highlighted studies showing HRT or MHT to play a limited role in increasing VTE risk, with most studies from the 1990s and 2000s. ConclusionsBased on current evidence, non-estrogen-containing transdermal HRT or MHT should not be withheld in patients undergoing elective joint arthroplasty, though further evidence is required to justify withholding estrogen-containing forms.

E-AHPBA-ESSO-ESSR Innsbruck consensus guidelines for preoperative liver function assessment before hepatectomy.

Posthepatectomy liver failure (PHLF) contributes significantly to morbidity and mortality after liver surgery. Standardized assessment of preoperative liver function is crucial to identify patients at risk. These European consensus guidelines provide guidance for preoperative patient assessment. A modified Delphi approach was used to achieve consensus. The expert panel consisted of hepatobiliary surgeons, radiologists, nuclear medicine specialists, and hepatologists. The guideline process was supervised by a methodologist and reviewed by a patient representative. A systematic literature search was performed in PubMed/MEDLINE, the Cochrane library, and the WHO International Clinical Trials Registry. Evidence assessment and statement development followed Scottish Intercollegiate Guidelines Network methodology. Based on 271 publications covering 4 key areas, 21 statements (at least 85 per cent agreement) were produced (median level of evidence 2- to 2+). Only a few systematic reviews (2++) and one RCT (1+) were identified. Preoperative liver function assessment should be considered before complex resections, and in patients with suspected or known underlying liver disease, or chemotherapy-associated or drug-induced liver injury. Clinical assessment and blood-based scores reflecting liver function or portal hypertension (for example albumin/bilirubin, platelet count) aid in identifying risk of PHLF. Volumetry of the future liver remnant represents the foundation for assessment, and can be combined with indocyanine green clearance or LiMAx® according to local expertise and availability. Functional MRI and liver scintigraphy are alternatives, combining FLR volume and function in one examination. These guidelines reflect established methods to assess preoperative liver function and PHLF risk, and have uncovered evidence gaps of interest for future research.

O02 Nitrofurantoin: what is the evidence for current guidance?

Abstract In this abstract, we review current approaches to the management of uncomplicated urinary tract infection (UTI) and begin to explore alternative approaches to antibiotic prescribing. We review clinical guidelines on the use of nitrofurantoin internationally to capture the level of variation in evidence-based guidance. We find that the evidence base has been interpreted in very different ways. UK guidelines from NICE and the Scottish Intercollegiate Guidelines Network (SIGN) are unusual in promoting short (3 day) courses of nitrofurantoin. We find little direct evidence to support this, and that this guidance has been extrapolated from studies based on other agents. ‘Short’ courses of antibiotics aim to provide optimum balance between providing effective treatment whilst reducing selective pressure driving resistance amongst colonizing microbial flora. Three days of nitrofurantoin may indeed be a useful intervention in a large group of patients. Longer courses of nitrofurantoin still demonstrate considerable rates of treatment failure. The concept of a course length in itself is limited. The variation between recommendations internationally reflects both the uncertain foundations upon which evidence-based guidelines are written, and the limits of what can be safely concluded from evidence. We join others in pointing out there may be ways of customizing duration of therapy to the patient’s response in primary care settings. There is a need for a more patient-focused approach to uncomplicated UTI, including better safety-netting and (currently lacking) guidance on best practice in the common clinical scenario of treatment failure.

Summary of the best evidence for the use of mechanical insufflation-exsufflation technique in invasive mechanical ventilation patients

To search and evaluate the literatures on the application of mechanical insufflation-exsufflation technique (MI-E) in patients with invasive mechanical ventilation in China and abroad, and to summarize the best evidence to provide evidence-based basis for clinical practice. The literatures related to the use of MI-E technique in invasive mechanical ventilation patients were searched from the establishment of the database to April 1, 2022 in BMJ Best Practice, UpToDate Clinical Advisor, Scottish Intercollegiate Guidelines Network (SIGN), Guidelines International Network (GIN), National Institute for Health and Care Excellence (NICE), National Guideline Clearinghouse (NGC), Registered Nurses' Association of Ontario (RNAO), medlive, Cochrane Library, Joana Briggs Instiute, Web of Science, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SinoMed, China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science and Technology Journal Database, and Website of American Association for Respiratory Care, including guideline, expert consensus, clinical decision, evidence summary, systematic review and randomized controlled trial. The JBI Center for Evidence-Based Health Care Expert Consensus Evaluation Criteria (2016) was used to evaluate the quality of the included systematic reviews; the JBI Center for Evidence-Based Health Care Evaluation Criteria for Randomized Controlled Trials was used to evaluate the quality of the included randomized controlled trial. Two researchers independently evaluated the quality of literature, and extracted and summarized the evidence based on professional judgment. A total of 7 literatures were enrolled, including 3 systematic reviews and 4 randomized controlled trials. After quality evaluation, 7 articles were all enrolled. Thirteen best evidences were formed from four aspects of indications, contraindications, parameter settings, and attention. The study summarizes the best evidence for the application of MI-E technique in invasive mechanical ventilation patients. It is recommended that medical staff undergo professional training, combined with their professional judgment as well as the patient's clinical specific conditions and willingness, and accurately apply MI-E technology to invasive mechanical ventilation patients.

ESPEN guideline on chronic intestinal failure in adults – Update 2023

Background & aimsIn 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. MethodsThe grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. ResultsThe recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is “strong consensus” for 148 (99.3%) and “consensus” for one (0.7%) recommendation. The grade of consensus for the statements is “strong consensus” for 14 (87.5%) and “consensus” for two (12.5%). ConclusionsIt is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Effect of thrombocytosis on cardiovascular risk in rheumatoid arthritis

BACKGROUND: Patients with rheumatoid arthritis have a high level of comorbidity, and their most common and socially significant conditions are cardiovascular diseases, which represent a major cause of mortality. Currently, there are no data on the differences in cardiovascular risk scales in patients with rheumatoid arthritis depending on the presence or absence of thrombocytosis.&#x0D; AIM: To assess and compare cardiovascular risk according to conventional scales in patients with thrombocytosis and normal thrombocytes.&#x0D; MATERIALS AND METHODS: The study involved 85 patients diagnosed with rheumatoid arthritis: 40 with thrombocytosis [including 25 (62,5%) women] and 45 with normal thrombocytes [including 29 (64,4%) women]. The following scales were used to assess risk of cardiovascular complications: Systematic COronary Risk Evaluation with adjustment factor 1.5 (mSCORE), Reynolds Risk Score (RRS), QRESEARCH Cardiovascular Risk Algorithm (QRISK3), Assessing Cardiovascular Risk to Scottish Intercollegiate Guidelines Network / SIGN to Assign Preventative Treatment (ASSIGN).&#x0D; RESULTS: The obtained findings have demontrated that according to the mSCORE and RRS scales the patients of both groups had almost identical parameters; however, according to the ASSIGN and QRISK3 high risk of cardiovascular complications has been detected nearly twice as frequently in the patients with rheumatoid arthritis and thrombocytosis in comparison with those with normal level of thrombocytes. It is also worth noting that more frequent determination of high risk of cardiovascular complications by the QRISK3 was statistically significant.&#x0D; CONCLUSIONS: The QRISK3 calculation has shown significantly higher prevalence of high-risk cardiovascular complications among the patients with platelet counts 450 ∙ 109/l compared with those with platelet levels within the reference values. Thus, the QRISK3 scale can be considered as more informative for estimating risk of cardiovascular complications in rheumatoid arthritis.

The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS).

To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery. Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update. Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE II-GRS tool for guideline quality assessment and external validation by a Validation Committee. Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee. The EGUMIPS evidence-based guidelines on laparoscopic and robotic MIPS can be applied in current clinical practice to provide guidance to patients, surgeons, policy-makers, and medical societies.

Evidence-based appraisal of two guidelines for the diagnosis of suspected, uncomplicated urinary tract infections in primary care: a diagnostic accuracy validation study.

Given the lack of accurate rapid diagnostics for urinary tract infection (UTI) in women, many countries have developed guidelines aiming to support appropriate antibiotic prescribing, but some guidelines have not been validated. We performed a diagnostic accuracy validation study of two guidelines: Public Health England (GW-1263) and Scottish Intercollegiate Guidelines Network (SIGN160). We used data from women with symptoms suggestive of uncomplicated UTI from a randomized controlled trial comparing urine collection devices. Symptom information was recorded via baseline questionnaire and primary care assessment. Women provided urine samples for dipstick testing and culture. We calculated the number within each risk category of diagnostic flowcharts who had positive/mixed growth/no significant growth urine culture. Results were presented as positive/negative predictive values, with 95% CIs. Of women aged under 65 years, 311/509 (61.1%, 95% CI 56.7%-65.3%) classified to the highest risk category (recommended to consider immediate antibiotic prescribing) and 80/199 (40.2%, 95% CI 33.4%-47.4%) classified to the lowest risk category (recommended to reassure that UTI is less likely) by the GW-1263 guideline (n = 810) had positive culture. For the SIGN160 guideline (n = 814), the proportion with positive culture ranged from 60/82 (73.2%, 95% CI 62.1%-82.1%) in those for whom immediate treatment was indicated to 33/76 (43.4%, 95% CI 32.3%-55.3%) in those recommended a self-care/waiting strategy. Clinicians should be aware of the potential for diagnostic error when using diagnostic guidelines for managing uncomplicated UTI and making antimicrobial prescribing decisions. Infection cannot be excluded on the basis of symptoms and dipstick testing alone.