Scottish Intercollegiate Guidelines Network Research Articles

The Scottish Intercollegiate Guidelines Network (SIGN) 157: Guidelines on Risk Reduction and Management of Delirium.

The Scottish Intercollegiate Guidelines Network (SIGN) guideline on delirium is a major advance on existing guidelines on this condition. This is particularly important given the evidence it is frequently under-diagnosed and inadequately managed despite being common and frequently associated with significant patient and carer distress and poor outcomes. The guidelines recommend using the 4A’s test to help detect delirium. A bundle of mostly non-pharmacological therapies minimise the risk of developing delirium and can help those who develop the condition. The importance of medical optimisation by an experienced professional in those at risk of delirium is highlighted with new recommendations for people in intensive care and surgical settings. There is guidance on follow-up of people with delirium, which should become routine. This commentary piece focusses on areas with the greatest potential to improve the experience and outcomes of those with delirium, and briefly discusses areas of ongoing uncertainty.

Evidence summary of procedural pain management for pediatric patients over three years old

Objective To search and summarize the best evidence of nursing management of procedural pain in pediatric patients so as to provide guidance for clinical nursing staff in the standardized prevention and management of procedural pain. Methods The Cochrane Database of Systematic Reviews, JBI Database of Systematic Reviews, National Guideline Clearinghouse (NGC) , the National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guideline Network (SIGN) were searched on computer to collect literature including clinical practice guidelines, evidence summary and systemic reviews about the management of procedural pain among children 3 years old above. Two researchers independently assessed the quality and extracted data and conducted evidence extraction from the articles that met the standard of quality. Results Totally eleven articles were enrolled including three best practice guidelines, three systematic reviews and five evidence summaries. Conclusions Cognitive behavioral intervention, topical application of epidermal anesthetics or local cold compress, and combined operation of distraction can effectively reduce the pain and anxiety caused by procedures. The knowledge and skills of procedural pain management should be included in the education and training courses of medical institutions. Evidence should be selected pertinently to participate in the management of procedural pain in the mode of multidisciplinary cooperation. Key words: Child; Evidence-based nursing; Procedural pain; Pain management

Real-life prescribing of asthmatic treatments in UK general practice over time using 2014 BTS/SIGN steps

The 2014 British Thoracic Society (BTS) and Scottish Intercollegiate Guideline Network (SIGN) guidelines recommend a stepwise approach to asthma management. We investigated the management of asthma in primary care in the UK to understand how real-world practice compares with BTS/SIGN guidelines. Asthma patients were identified from the UK Clinical Practice Research Datalink from September 2006 to August 2016. Aims were to classify patients according to BTS/SIGN steps, describe the proportion of patients transitioning between steps and describe patient demographics and clinical characteristics per group. Overall, 647,308 patients with asthma were identified (40,096 aged 5–11 years; 607,212 aged 12–80 years). Most treated patients were in step 1 or 2 (88.3% of children/67.5% of adults in December 2007; 83.0% of children/67.0% of adults in June 2016). Most patients remained within their treatment step within a 6-month interval (>78% of children and adults throughout the study duration). The proportion of patients stepping up and down reduced from the beginning of the study, although stepping down to step 1 was relatively common in both adults and children. Few patients had a recorded asthma review in the year before reference date (18.8% of children and 14.8% of adults). Although prescribing patterns meant that most patients remained within their treatment step throughout the study, we cannot be sure that this was because their disease was truly stable. The small proportion of patients stepping up/down and the lack of recorded asthma review suggest that patients may not be treated in accordance with BTS/SIGN guidelines.

Nutrition Interventions in Pediatric Pancreatitis: Guidelines We Can Trust.

Despite the fact that pediatric pancreatitis is an uncommon disease, its prevalence has increased in recent years. Nevertheless, until 4 years ago, the lack of nutritional guidelines for pediatric pancreatitis was evident, with all recommendations being based on clinical practice guidelines (CPGs) for adults. The aim of the present study was to review and critically appraise guidelines for the medical nutrition therapy (MNT) of pediatric pancreatitis. A comprehensive search was performed in electronic databases (PubMed, Scopus, National Institute for Health and Care Excellence), the International Guidelines Network, BMJ best practice, and the Scottish Intercollegiate Guidelines Network to identify CPGs on the MNT of pediatric pancreatitis. The validated AGREE II tool was used for guidelines appraisal by a team of 3 independent multidisciplinary reviewers. A total of 4 CPGs were retrieved with pediatric pancreatitis MNT information. Out of the 4 advising bodies in total, the joint society paper published by the ESPGHAN/NASPGHAN received the highest score in almost all domains, whereas the Belgian consensus obtained the lowest score in all domains but stakeholder involvement, and was not recommended by 2 out of 3 reviewers. Pediatric pancreatitis guidelines appear heterogenous in quality, rigour, and transparency. Our study points out existing gaps and biases in the CPGs, and delineates the need for improving the domains identified as being of low-quality.

A summary of evidence for diabetic foot assessment

Objective To search, appraise and summarize the best evidence of the diabetic foot assessment and provide a reference for the standardization of the clinical diabetic foot evaluation in China. Methods On the computer, the following websites as well as databases were searched: National Guideline Clearinghouse (NGC) of the USA, Registered Nurses' Association of Ontario (RNAO) , National Institute for Health and Care Excellence (NICE) of UK, the Scottish Intercollegiate Guidelines Network (SIGN) , New England Guidelines Group (NEGG) , International Guidelines Network (IGN) , American Center for Disease Control and Prevention (ACDC) , World Council of Enterostomal therapists (WCET) , Wound Ostomy Continence Nurses Society (WOCN) , the International Working Group on Diabetic Foot (IWGDF) , American Society for Wound Healing, American Diabetes Association (ADA) , American Society for Vascular Surgery (ASVS) , Society of Endocrinology of Chinese Medical Association, Clinical evidence, PubMed, ProQuest, Web of Science, Clinical Key, CINAHL, Best Practice, CNKI, VIP, Wanfang Data, Medlive from January of 2010 to July of 2018 about all evidence-based clinical practice guidelines and systematic reviews on assessment of diabetic foot. Two researchers evaluated the quality of the articles and performed materials extraction, and extracted the evidence from the qualified articles. Results A total of 7 articles were included among which 6 were guidelines and 1 was systemic review. After analyzing them, 9 categories and 32 items of the best evidence contents about diabetic foot assessment were concluded. Conclusions This study summarizes the best evidence for assessment of diabetic foot and provide evidence basis for medical institutions to improve clinical practice of diabetic foot assessment. When applying the evidence into clinical practice, it is necessary to evaluate specific situations, consider patients' values and willingness and select targeted evidence accordingly. Key words: Diabetic foot; Foot ulcer; Assessment; Best evidence; Evidence summary

Getting lower leg ulcer evidence into primary health care nursing practice: a case study

Venous leg ulcers (VLUs) are open lesions on the lower leg caused by venous disease, which are associated with high morbidity and pose a challenge to manage effectively (Scottish Intercollegiate Guidelines Network, 2010). Gold standard treatment for VLUs is graduated compression therapy to aid venous return. This paper presents an approach to the challenging management of VLUs that is based on a problem, and subsequent local audit. We use a case study that illustrates a collaborative approach to determine gaps in evidence-based practice (EBP), and a nurse-led initiative in consultation with executive managers and doctors. In our sample, 40% of patients had not consulted a vascular specialist. They did not have a formal diagnosis of leg ulcer aetiology and therefore had not received optimum treatment. Access and cost were main factors impacting on leg ulcer care. Nurses providing evidence-based management of VLUs should ensure collaboration with key stakeholders. This assists in implementing diagnosis of ulcer aetiology for best practice measures. At this local health district, a change in policy to reflect EBP for VLU management in primary health care has been achieved.

Incorporating qualitative evidence in clinical practice guidelines: a Scottish perspective.

The current article provides an overview of an approach to incorporating a range of evidence, including qualitative research findings, which the authors piloted when developing a clinical guideline on epilepsies in children and young people. We describe methods used for incorporating literature types not usually included in Scottish Intercollegiate Guidelines Network guidelines, including critical appraisal, and establishing dependability and credibility of qualitative findings. We highlight limitations encountered and make suggestions for future work.

Recommendations from clinical practice guidelines on discussion of costs of care in adult patients with advanced cancer: A systematic review.

e23175 Background: Optimising the care of cancer patients without imposing significant financial burden related to their anticancer treatment is becoming increasingly difficult. The 2009 American Society of Clinical Oncology’s (ASCO) Guidance Statement on the Cost of Cancer Care recommends that ‘patient-physician discussions regarding the cost of care are an important component of high-quality care’.(1) We sought information for oncologists to facilitate patient-clinician communication about the costs of care in published clinical practice guidelines (CPGs). Methods: We searched MEDLINE, EMBASE and multiple databases of CPG from January 2008 to 1st June 2018 for recommendations about discussing the costs of care. We assessed quality with the AGREE II instrument for the assessment of guidelines. Results: We identified 471 publications, of which 25 guidelines met our eligibility criteria. Most guidelines were from ASCO (64%, 16/25) and the Scottish Intercollegiate Guidelines Network (SIGN, 24%, 6/25). Guidelines included recommendations on discussion or consideration of treatment costs when prescribing in 52% (13/25) with information about actual costs in only 20% (5/25). Recognition of the risk of financial burden or financial toxicity was described in 60% (15/25) of guidelines, however, only a minority of these, 28% (7/25) contained information regarding management of patients with financial concerns. Conclusions: Current CPGs have limited information to guide patient-clinician communication about the costs of anticancer treatment and management of financial burden. Future guidelines should contain more information about the optimal timing, frequency, and content of these discussions. Future guidelines should include more guidance about how oncologists should communicate the costs of care accurately and transparently, along with suggestions to reduce financial burden.

Exploring the barriers to the implementation of cognitive behavioural therapy for psychosis (CBTp)

Purpose The purpose of this paper is to identify barriers for people with psychotic spectrum disorders accessing CBTp in NHS Lothian. Despite national guidelines recommending CBT for the treatment of schizophrenia (National Institute for Health and Care Excellence Guidelines 2014) and (Scottish Intercollegiate Guidelines Network Guidelines 2013), levels of access to CBTp remain low. The overall goal of the study is to uncover emergent themes regarding barriers to access to CBT for patients with psychosis. In addition, the influence of psychosocial skills intervention (PSI) training for psychosis (Brooker and Brabban, 2006) will be explored and if completion of this training effects referral behaviours and attitudes to CBTp. Design/methodology/approach This study is a quantitative service evaluation project which uses a questionnaire design to explore the factors that influence a clinician’s decision to refer a patient for CBTp. Three qualitative questions are included for thematic analysis to allow the respondents to elaborate on their views on potential barriers. All appropriate Community Mental Health Team (CMHT) staff in adult mental health in NHS Lothian were invited to participate in the study. Findings CMHT staff in NHS Lothian hold favourable views of CBTp and would support an increase in access for patients with psychosis. Key barriers to access for CBTp identified in this study comprise of, little or no access to CBTp, lack of integration of services and unclear referral pathways. Further themes emerging from the study also included, improving multi-disciplinary communication and increasing CMHT staff knowledge and confidence in CBTp. PSI training was shown to have a significant effect on referral rates. Further research would be warranted to explore the influence of PSI training on CMHT staff confidence and knowledge in CBTp. Originality/value This is the first paper of its kind to investigate the potential barriers to access to CBTp in Scotland. The paper has highlighted some key barriers and potential strategies to overcome the barriers identified will be discussed.

Comparison of different algorithms for the assessment of cardiovascular risk after kidney transplantation by the time of entering waiting list.

BackgroundThe prevalence of cardiovascular disease is high among patients with chronic kidney disease and cardiovascular events (CVE) remain the leading cause of death after kidney transplantation (KT). We performed a retrospective analysis of 389 KT recipients to assess if the European Society of Cardiology Score (ESC-Score), Framingham Heart Study Score (FRAMINGHAM), Prospective Cardiovascular Munster Study Score (PROCAM-Score) or Assessing cardiovascular risk using Scottish Intercollegiate Guidelines Network Score (ASSIGN-Score) algorithms can predict cardiovascular risk after KT at the time of entering the waiting list.Methods389 KT candidates were scored by the time of entering the waiting list. Pearsons chi-square test, cox regression analysis and survival estimates were performed to evaluate the reliability of the cardiovascular scoring models after successful KT.ResultsDuring a follow-up of 8 ± 5.8 years, 96 patients (30%) died due to cardiovascular problems, whereas 13.9% suffered non-fatal CVE. Graft loss occurred in 84 patients (21.6%). Predictors of CVE, survival and graft loss were age and the length of end-stage kidney disease. All scores performed well in assessing the risk for CVE (P < 0.01). Receiver-operating characteristic analysis using the ESC-SCORE, as an example, suggested a cut-off for risk stratification and clinical decisions.ConclusionsWe found all tested scores were reliable for cardiovascular assessment. We suggest using cardiac scores for risk assessment before KT and then taking further steps according to current guidelines.

Psychological Therapies in Management of Psoriatic Skin Disease: A Systematic Review.

Psoriasis is a chronic, immune-mediated skin disease shown to have a multifaceted relationship with psychological factors. Because these factors have been shown to both worsen and result from psoriasis, an increasing number of studies have sought to investigate the efficacy of various psychological interventions in psoriasis management. A systematic review of PubMed® and Scopus® databases was performed for studies investigating psychological interventions in psoriasis management published from 1 January 1990 through 4 November 2018. Primary articles published in English and conveying physical treatment outcomes were included, whereas articles not describing clinical outcomes were excluded. Studies supporting intervention efficacy were graded with a level of evidence according to the Scottish Intercollegiate Guidelines Network levels of evidence. A total of 28 reports studying 27 unique sets of patients receiving psychological therapies in psoriasis management were identified, including three case reports and series and 24 clinical trials, investigating 1522 patients in total. Cognitive behavioral therapy and its variants, biofeedback, meditation and mindfulness-based therapies, hypnosis, music resonance therapy, motivational interviewing, emotional disclosure, and educational and multidisciplinary approaches have been studied in the treatment of psoriasis. Although 16 randomized controlled trials were included in this review, literature is limited by heterogeneity of methodology, analyses, and outcomes. Only 4 of 27 studies (three of which investigated cognitive behavioral therapy) were rated a level of evidence of 1+ or greater. Studies, overall, have sample sizes often < 50 patients, lack follow-up past 12months, and have attrition rates > 20%. Based on assigned levels of evidence, the most promising methods of psychological intervention in psoriasis include cognitive behavioral therapy, mindfulness-based therapies, motivational interviewing, and educational and interdisciplinary interventions. Further study is needed to determine the efficacy, practicality, and economic feasibility of these treatment options for patients with psoriasis.

The Scottish Intercollegiate Guidelines Network: risk reduction and management of delirium.

Clinical and research interest in delirium has been rising over the last 15 years. The Scottish Intercollegiate Guidelines Network (SIGN) publication on delirium is a state-of-the-art synthesis of the field, and the first UK guideline since 2010. There is new guidance around delirium detection, particularly in recommending the 4 'A's Test (4AT). The 4AT has the advantage of being brief, embeds and operationalises cognitive testing, and is scalable with little training. The guidelines highlight the importance of non-pharmacological management for all hospital presentations involving the spectrum of cognitive disorders (delirium, dementia but at risk of delirium, delirium superimposed on dementia). Pharmacotherapy has a minimal role, but specific indications (e.g. intractable distress) are discussed. Advances in delirium research, education and policy, have come together with steady changes in the sociocultural context in which healthcare systems look after older people with cognitive impairment. However, there remains a gap between desired and actual clinical practice, one which might be bridged by re-engaging with compassionate, patient-centred care. In this respect, these SIGN guidelines offer a key resource.

Fractional Exhaled Nitric Oxide Values in Indigenous Australians 3 to 16 Years of Age

Fractional exhaled nitric oxide (Feno) levels can identify eosinophilic asthma phenotypes. We aimed to determine Feno values of healthy Aboriginal and/or Torres Strait Islander (Indigenous) Australians, differences between these Indigenous ethnic groups, and appropriateness of published cutoff values. We measured Feno levels in 1,036 Indigenous Australians (3-16 years of age). Participants were classified into healthy (ie, no asthma or atopy history) or asthmatic and/or atopic groups. Median Feno values and distribution did not differ between Indigenous ethnicities. For healthy participants< 12 years of age (n= 390), 7.2%of our cohort fell into the inflammatory zone of the American Thoracic Society (ATS), National Institute for Health and Care Excellence (NICE), and British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) guidelines (cutoff 35 parts per billion [ppb]), but only 3.8%fell into this category when using the Global Initiative for Asthma (GINA) guidelines (50 ppb). Similarly, when using the NICE and BTS/SIGN guidelines (40 ppb) for participants 12 to 16 years of age (n= 213), more healthy participants fell into the inflammatory zone compared with the ATS and GINA guidelines (50 ppb) (9.9%vs4.7%, respectively). Feno values for healthy Indigenous Australians children (3-16 years of age) are likely higher than published white-based values. The GINA recommended cutoff value (>50 ppb) appears the most appropriate for identifying healthy Indigenous children but requires confirmation from a larger study.

Percepción del dolor según el modo de punción de la fístula arteriovenosa en pacientes sometidos a hemodiálisis. Revisión sistemática

Objetivo: Valorar la posible asociación entre la forma de punción de la fístula arteriovenosa y el dolor que siente el paciente por la inserción de la aguja. Metodología: Se ha seguido la declaración PRISMA para revisiones sistemáticas. Se han consultado 6 bases de datos; Medline, Scopus, Cuiden, CINAHL, SciELO, y Cochrane PLUS. Además, se realizó una búsqueda secundaría manual para detectar literatura gris no encontrada en las bases de datos o mediantes las estrategias definidas. Criterios de inclusión; estudios de nivel de evidencia 1 en la escala Scottish Intercollegiate Guidelines Network, publicados en los últimos 10 años, idiomas español/inglés, y temática relacionada con las técnicas utilizadas en hemodiálisis para el abordaje de la fistula. Los artículos se evaluaron de forma crítica para detectar cualquier riesgo de sesgo mediante el instrumento CASPe y el manual Cochrane para Revisiones Sistemáticas de Intervenciones. Resultados: Se identificaron un total de 150 resultados, seleccionándose finalmente 9 estudios. Los resultados han sido muy heterogéneas, encontrándose resultados para el dolor, tasas de infección, número de intentos de canalización, flujo sanguíneo, presión venosa, tiempo de hemostasia, seguridad, dilataciones aneurismáticas, estética del brazo portador de la fístula y calidad de vida del paciente. Conclusiones: La evidencia no respalda el uso preferencial de la técnica del ojal sobre la canalización tradicional. Por tanto, se necesita mejorar el rigor metodológico y un mayor tamaño muestral para dilucidar que técnica da mejores prestaciones respecto al dolor, permitiendo por tanto mejorar la calidad de vida de los pacientes de hemodiálisis.

Oral health-related quality of life and satisfaction of edentulous patients using conventional complete dentures and implant-retained overdentures: An umbrella systematic review.

Loss of teeth has a negative influence on essential oral functions. It is important to understand edentulous patients' perceptions about the impacts of treatment options on their oral health-related quality of life (OHRQoL) and satisfaction. To appraise the systematic reviews (with/without meta-analysis) that investigate the impacts of complete conventional dentures (CCDs) and/or implant-retained overdentures (IRODs) on the oral health-related quality of life (OHRQoL) and satisfaction among edentulous patients. The Joanna Briggs Institute (JBI) methodology for conduct of an umbrella systematic review was followed. Three database systems were used: Medline, Google Scholar and Cochrane Library. PROSPERO was searched for ongoing or recently completed systematic reviews. The reviews must report OHRQoL and patients' satisfaction as outcomes. A total of eight reviews were included in data synthesis (six were systematic reviews without meta-analysis, one was systematic review with meta-analysis, and one was meta-analysis). The level of evidence of all included reviews based on the Scottish Intercollegiate Guidelines Network ranged between 1+ and 1-. The results of this umbrella systematic review demonstrate the superiority of using IRODs compared with CCDs on the OHRQoL and patients' satisfaction outcomes. However, this positive impact is more accentuated when patients demand implant treatment or cannot adapt to CCDs treatment. Financial factors and adaptive capability indeed affect patient tolerance to both treatment modalities.

Manipulation and Mobilization for Treating Chronic Nonspecific Neck Pain: A Systematic Review and Meta-Analysis for an Appropriateness Panel

Background: Mobilization and manipulation therapies are widely used by patients with chronic nonspecific neck pain; however, questions remain around efficacy, dosing, and safety, as well as how these approaches compare to other therapies. Objectives: Based on published trials, to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic nonspecific neck pain. Study Design: A systematic literature review and meta-analysis. Methods: We identified studies published between January 2000 and September 2017, by searching multiple electronic databases, examining reference lists, and communicating with experts. We selected randomized controlled trials comparing manipulation and/or mobilization therapies to sham, no treatment, each other, and other active therapies, or when combined as multimodal therapeutic approaches. We assessed risk of bias by using the Scottish Intercollegiate Guidelines Network criteria. When possible, we pooled data using random-effects meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation was applied to determine the confidence in effect estimates. This project was funded by the National Center for Complementary and Integrative Health under award number U19AT007912 and ultimately used to inform an appropriateness panel. Results: A total of 47 randomized trials (47 unique trials in 53 publications) were included in the systematic review. These studies were rated as having low risk of bias and included a total of 4,460 patients with nonspecific chronic neck pain who were being treated by a practitioner using various types of manipulation and/or mobilization interventions. A total of 37 trials were categorized as unimodal approaches and involved thrust or nonthrust compared with sham, no treatment, or other active comparators. Of these, only 6 trials with similar intervention styles, comparators, and outcome measures/timepoints were pooled for meta-analysis at 1, 3, and 6 months, showing a small effect in favor of thrust plus exercise compared to an exercise regimen alone for a reduction in pain and disability. Multimodal approaches appeared to be effective at reducing pain and improving function from the 10 studies evaluated. Health-related quality of life was seldom reported. Some 22/47 studies did not report or mention adverse events. Of the 25 that did, either no or minor events occurred. Limitations: The current evidence is heterogeneous, and sample sizes are generally small. Conclusions: Studies published since January 2000 provide low-moderate quality evidence that various types of manipulation and/or mobilization will reduce pain and improve function for chronic nonspecific neck pain compared to other interventions. It appears that multimodal approaches, in which multiple treatment approaches are integrated, might have the greatest potential impact. The studies comparing to no treatment or sham were mostly testing the effect of a single dose, which may or may not be helpful to inform practice. According to the published trials reviewed, manipulation and mobilization appear safe. However, given the low rate of serious adverse events, other types of studies with much larger sample sizes would be required to fully describe the safety of manipulation and/or mobilization for nonspecific chronic neck pain. Key words: Chronic neck pain, nonspecific, chiropractic, manipulation, mobilization, systematic review, meta-analysis, appropriateness

Treatment Recommendations for Tardive Dyskinesia.

Tardive dyskinesia is a movement disorder characterised by irregular, stereotyped, and choreiform movements associated with the use of antipsychotic medication. We aim to provide recommendations on the treatment of tardive dyskinesia. We performed a systematic review of studies of the treatment of tardive dyskinesia. Studies were rated for methodological quality using the American Academy of Neurology Risk of Bias Classification system. Overall level of evidence classifications and grades of recommendation were made using the Scottish Intercollegiate Guidelines Network framework. Preventing tardive dyskinesia is of primary importance, and clinicians should follow best practice for prescribing antipsychotic medication, including limiting the prescription for specific indications, using the minimum effective dose, and minimising the duration of therapy. The first-line management of tardive dyskinesia is the withdrawal of antipsychotic medication if clinically feasible. Yet, for many patients with serious mental illness, the discontinuation of antipsychotics is not possible due to disease relapse. Switching from a first-generation to a second-generation antipsychotic with a lower D2 affinity, such as clozapine or quetiapine, may be effective in reducing tardive dyskinesia symptoms. The strongest evidence for a suitable co-intervention to treat tardive dyskinesia comes from tests with the new VMAT inhibitors, deutetrabenazine and valbenazine. These medications have not been approved for use in Canada. Data on tardive dyskinesia treatment are limited, and the best management strategy remains prevention. More long-term safety and efficacy data are needed for deutetrabenazine and valbenazine, and their routine availability to patients outside of the USA remains in question.

Modifying a Paediatric Rational Prescribing Tool (POPI) for Use in the UK.

Rational prescribing tools can be used by individual prescribers, organisations, and researchers to evaluate the quality of prescribing for research and quality improvement purposes. A literature search showed that there is only one tool for evaluating rational prescribing for paediatric patients in hospital and outpatient settings. The Pediatrics: Omission of Prescriptions and Inappropriate Prescriptions (POPI) tool was developed in France and comprises 105 criteria. The aim of this study was to modify this tool to facilitate its use in paediatric practice in the United Kingdom (UK). POPI criteria were compared to relevant UK clinical guidelines from the National Institute for Health and Care Excellence, the Scottish Intercollegiate Guideline Network and the British National Formulary for Children. Where guidelines differed, criteria were modified to reflect UK guidance. If there were no relevant guidelines or directly contradictory guidelines, criteria were removed. Overall, no change was made to 49 criteria. There were 29 modified to concord with UK guidelines. Four criteria were reduced to two criteria due to being linked in single guidelines. Twenty-three criteria were omitted, due to the absence of relevant UK guidance or directly conflicting UK practice, including one entire clinical category (mosquitos). One category title was amended to parallel UK terminology. The modified POPI (UK) tool comprises of eighty criteria and is the first rational prescribing tool for the evaluation of prescribing for children in hospital and outpatient settings in the UK.

Clozapine augmentation strategies - a systematic meta-review of available evidence. Treatment options for clozapine resistance.

Treatment options for clozapine resistance are diverse whereas, in contrast, the evidence for augmentation or combination strategies is sparse. We aimed to extract levels of evidence from available data and extrapolate recommendations for clinical practice. We conducted a systematic literature search in the PubMed/MEDLINE database and in the Cochrane database. Included meta-analyses were assessed using Scottish Intercollegiate Guidelines Network criteria, with symptom improvement as the endpoint, in order to develop a recommendation grade for each clinical strategy identified. Our search identified 21 meta-analyses of clozapine combination or augmentation strategies. No strategies met Grade A criteria. Strategies meeting Grade B included combinations with first- or second-generation antipsychotics, augmentation with electroconvulsive therapy for persistent positive symptoms, and combination with certain antidepressants (fluoxetine, duloxetine, citalopram) for persistent negative symptoms. Augmentation strategies with mood-stabilisers, anticonvulsants, glutamatergics, repetitive transcranial magnetic stimulation, transcranial direct current stimulation or cognitive behavioural therapy met Grades C-D criteria only. More high-quality clinical trials are needed to evaluate the efficacy of add-on treatments for symptom improvement in patients with clozapine resistance. Applying definitions of clozapine resistance would improve the reporting of future clinical trials. Augmentation with second-generation antipsychotics and first-generation antipsychotics can be beneficial, but the supporting evidence is from low-quality studies. Electroconvulsive therapy may be effective for clozapine-resistant positive symptoms.

Effectiveness of stop smoking interventions among adults: protocol for an overview of systematic reviews and an updated systematic review

BackgroundTobacco smoking is the leading cause of cancer, preventable death, and disability. Smoking cessation can increase life expectancy by nearly a decade if achieved in the third or fourth decades of life. Various stop smoking interventions are available including pharmacotherapies, electronic cigarettes, behavioural support, and alternative therapies. This protocol outlines an evidence review which will evaluate the benefits and harms of stop smoking interventions in adults.MethodsThe evidence review will consist of two stages. First, an overview of systematic reviews evaluating the benefits and harms of various stop smoking interventions delivered in or referred from the primary care setting will be conducted. The second stage will involve updating a systematic review on electronic cigarettes identified in the overview; randomized controlled trials will be considered for outcomes relating to benefits while randomized controlled trials, non-randomized controlled trials, and comparative observational studies will be considered for evaluating harms. Search strategies will be developed and peer-reviewed by medical information specialists. The search strategy for the updated review on e-cigarettes will be developed using that of the candidate systematic review. The MEDLINE®, PsycINFO, Embase, and the Cochrane Library electronic databases will be searched as of 2008 for the overview of reviews and from the last search date of the selected review for the updated review. Organizational websites and trial registries will be searched for unpublished or ongoing reviews/studies. Two reviewers will independently screen the title and abstracts of citations using the liberal accelerated method. Full-text screening will be performed independently by two reviewers. Extracted data will be verified by a second reviewer. Disagreements regarding full-text screening and data extraction will be resolved by consensus or third-party adjudication. The methodological quality of systematic reviews, risk of bias of randomized and non-randomized trials, and methodological quality of cohort studies will be evaluated using AMSTAR 2, the Cochrane risk of bias tool, and a modified version of the Scottish Intercollegiate Guidelines Network critical appraisal tool, respectively. The GRADE framework will be used to assess the quality of the evidence for outcomes.DiscussionThe evidence review will evaluate the benefits and harms of various stop smoking interventions for adults. Findings will be used to inform a national tobacco cessation guideline by the Canadian Task Force on Preventive Health Care.Systematic review registrationPROSPERO (CRD42018099691, CRD42018099692)