Scottish Intercollegiate Guidelines Network Research Articles

NUQUEST—NUtrition QUality Evaluation Strengthening Tools: development of tools for the evaluation of risk of bias in nutrition studies

ABSTRACTBackgroundDietary exposure assessments are a critical issue in evaluating human nutrition studies; however, nutrition-specific criteria are not consistently included in existing bias assessment tools.ObjectivesOur objective was to develop a set of risk of bias (RoB) tools that integrated nutrition-specific criteria into validated generic assessment tools to address RoB issues, including those specific to dietary exposure assessment.MethodsThe Nutrition QUality Evaluation Strengthening Tools (NUQUEST) development and validation process included 8 steps. The first steps identified 1) a development strategy; 2) generic assessment tools with demonstrated validity; and 3) nutrition-specific appraisal issues. This was followed by 4) generation of nutrition-specific items and 5) development of guidance to aid users of NUQUEST. The final steps used established ratings of selected studies and feedback from independent raters to 6) assess reliability and validity; 7) assess formatting and usability; and 8) finalize NUQUEST.ResultsNUQUEST is based on the Scottish Intercollegiate Guidelines Network checklists for randomized controlled trials, cohort studies, and case-control studies. Using a purposive sample of 45 studies representing the 3 study designs, interrater reliability was high (Cohen's κ: 0.73; 95% CI: 0.52, 0.93) across all tools and at least moderate for individual tools (range: 0.57–1.00). The use of a worksheet improved usability and consistency of overall interrater agreement across all study designs (40% without worksheet, 80%–100% with worksheet). When compared to published ratings, NUQUEST ratings for evaluated studies demonstrated high concurrent validity (93% perfect or near-perfect agreement). Where there was disagreement, the nutrition-specific component was a contributing factor in discerning exposure methodological issues.ConclusionsNUQUEST integrates nutrition-specific criteria with generic criteria from assessment tools with demonstrated reliability and validity. NUQUEST represents a consistent and transparent approach for evaluating RoB issues related to dietary exposure assessment commonly encountered in human nutrition studies.

Research Trends in Korea of the Inspiratory Muscle Training Applied to Stroke Patients: A Systematic Review

Purpose : This study aimed to analyze the effectiveness of inspiratory muscle training(IMT) studies for stroke patients conducted over the past 10 years(2011–2020) in Korea. Methods : Previous literature was electronically searched using the RISS, KISS, KCI, and NDSL databases. Tree databases were searched for stroke IMT articles. A total of 12 studies were selected according to the PRISMA guidelines, and the Jeong’g qualitative evaluation criteria were used to refer to the checklist presented by the Scottish Intercollegiate Guideline Network. Results : Twelve studies met the criteria. In a qualitative evaluation on the papers, one study scored 8 out of 10, seven scored between 6 and 7, and four scored 5. Intervention sessions were conducted between 20 and 30 min, each at a frequency of three to five sessions per week, for a total of 4–8 weeks. The results indicated that IMT effectively improved respiratory function, physical activity, and respiratory muscle function in stroke patients. Conclusion : IMT was found to have a positive effect on respiratory function, physical activity, and respiratory muscle function in stroke patients.

A Systematic Review on Comparative Analyses between Ureteroscopic Lithotripsy and Shock-Wave Lithotripsy for Ureter Stone According to Stone Size.

Background and Objectives: This systematic review and meta-analysis was conducted to analyze the treatment outcomes of shock wave lithotripsy (SWL) and ureteroscopic lithotripsy (URSL) according to the ureteral stone size. Materials and Methods: In this systematic review, relevant articles that compared SWL and URSL for treatment of ureteral stones were identified. Articles were selected from four English databases including Ovid-Medline, Ovid-EMBASE, the Cochrane Central Register of controlled Trials (Central), and Google Scholar. A quality assessment was carried out by our researchers independently using the Scottish Intercollegiate Guidelines Network (SIGN). A total of 1325 studies were identified, but after removing duplicates, there remained 733 studies. Of these studies, 439 were excluded, 294 were screened, and 18 met the study eligibility criteria. Results: In randomized control trial (RCT) studies, URSL showed significantly higher SFR than SWL (p < 0.01, OR= 0.40, 95% CI 0.30–0.55, I² = 29%). The same results were shown in sub-group analysis according to the size of the stone (<1 cm: p < 0.01, OR = 0.40, 95% CI 0.25–0.63; >1 cm: p < 0.01, OR = 0.38, 95% CI 0.19–0.74, I² = 55%; not specified: p < 0.01, OR = 0.43, 95% CI 0.25–0.72, I² = 70%). In the non-RCT studies, the effectiveness of the URSL was significantly superior to that of SWL (p < 0.01, OR = 0.33, 95% CI 0.21–0.52, I² = 83%). Retreatment rate was significantly lower in URSL than in SWL regardless of stone size (p < 0.01, OR = 10.22, 95% CI 6.76–15.43, I² = 54%). Conclusions: Meta-analysis results show that SFR was higher than SWL in URSL and that URSL was superior to SWL in retreatment rate. However, more randomized trials are required to identify definitive conclusions.

Objectively Measured Physical Activity, Sedentary Behavior and Functional Performance before and after Lower Limb Joint Arthroplasty: A Systematic Review with Meta-Analysis.

Patients after joint arthroplasty tend to be less physically active; however, studies measuring objective physical activity (PA) and sedentary behavior (SB) in these patients provide conflicting results. The aim of this meta-analysis was to assess objectively measured PA, SB and performance at periods up to and greater than 12 months after lower limb arthroplasty. Two electronic databases (PubMed and Medline) were searched to identify prospective and cross-sectional studies from 1 January 2000 to 31 December 2020. Studies including objectively measured SB, PA or specific performance tests in patients with knee or hip arthroplasty, were included in the analyses both pre- and post-operatively. The risk of bias was assessed using the Scottish Intercollegiate Guidelines Network (SIGN). After identification and exclusion, 35 studies were included. The data were analyzed using the inverse variance method with the random effects model and expressed as standardized mean difference and corresponding 95% confidence intervals. In total, we assessed 1943 subjects with a mean age of 64.9 (±5.85). Less than 3 months post-operative, studies showed no differences in PA, SB and performance. At 3 months post-operation, there was a significant increase in the 6 min walk test (6MWT) (SMD 0.65; CI: 0.48, 0.82). After 6 months, changes in moderate to vigorous physical activity (MVPA) (SMD 0.33; CI: 0.20, 0.46) and the number of steps (SMD 0.45; CI: 0.34, 0.54) with a large decrease in the timed-up-and-go test (SMD −0.61; CI: −0.94, −0.28) and increase in the 6MWT (SMD 0.62; CI: 0.26–0.98) were observed. Finally, a large increase in MVPA (SMD 0.70; CI: 0.53–0.87) and a moderate increase in step count (SMD 0.52; CI: 0.36, 0.69) were observed after 12 months. The comparison between patients and healthy individuals pre-operatively showed a very large difference in the number of steps (SMD −1.02; CI: −1.42, −0.62), but not at 12 months (SMD −0.75; −1.89, 0.38). Three to six months after knee or hip arthroplasty, functional performance already exceeded pre-operative levels, yet PA levels from this time period remained the same. Although PA and functional performance seemed to fully restore and exceed the pre-operation levels at six to nine months, SB did not. Moreover, PA remained lower compared to healthy individuals even longer than twelve months post-operation. Novel rehabilitation protocols and studies should focus on the effects of long-term behavioral changes (increasing PA and reducing SB) as soon as functional performance is restored.

Augmented Reality in Physical Therapy: Systematic Review and Meta-analysis.

BackgroundAugmented reality (AR) is a rapidly expanding technology; it comprises the generation of new images from digital information in the real physical environment of a person, which simulates an environment where the artificial and real are mixed. The use of AR in physiotherapy has shown benefits in certain areas of patient health. However, these benefits have not been studied as a whole.ObjectiveThis study aims to ascertain the current scientific evidence on AR therapy as a complement to physiotherapy and to determine the areas in which it has been used the most and which variables and methods have been most effective.MethodsA systematic review registered in PROSPERO (International Prospective Register of Systematic Reviews) was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) recommendations. The search was conducted from July to August 2021 in the PubMed, PEDro, Web of Science, Scopus, and Cochrane Library scientific databases using the keywords augmented reality, physiotherapy, physical therapy, exercise therapy, rehabilitation, physical medicine, fitness, and occupational therapy. The methodological quality was evaluated using the PEDro scale and the Scottish Intercollegiate Guidelines Network scale to determine the degree of recommendation. The Cochrane Collaboration tool was used to evaluate the risk of bias.ResultsIn total, 11 articles were included in the systematic review. Of the 11 articles, 4 (36%) contributed information to the meta-analysis. Overall, 64% (7/11) obtained a good level of evidence, and most had a B degree of recommendation of evidence. A total of 308 participants were analyzed. Favorable results were found for the Berg Balance Scale (standardized mean change 0.473, 95% CI −0.0877 to 1.0338; z=1.65; P=.10) and the Timed Up and Go test (standardized mean change −1.211, 95% CI −3.2005 to 0.7768; z=−1.194; P=.23).ConclusionsAR, in combination with conventional therapy, has been used for the treatment of balance and fall prevention in geriatrics, lower and upper limb functionality in stroke, pain in phantom pain syndrome, and turning in place in patients with Parkinson disease with freezing of gait. AR is effective for the improvement of balance; however, given the small size of the samples and the high heterogeneity of the studies, the results were not conclusive. Future studies using larger sample sizes and with greater homogeneity in terms of the devices used and the frequency and intensity of the interventions are needed.Trial RegistrationPROSPERO International Prospective Register of Systematic Reviews CRD42020180766; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=180766

P-BN03 A systematic review of pre-operative low-calorie diets for laparoscopic cholecystectomy

Abstract Background Laparoscopic cholecystectomy is the fourth most common procedure in the UK. Increased liver adiposity, commonly encountered in obesity, anecdotally may increase technical difficulty and surgical risk. Pre-operative low-calorie diets are well-established in bariatric surgery to reduce liver bulk, thereby ameliorating difficulty and risk. Similar diets are often used before laparoscopic cholecystectomy, however, the supporting evidence base is unclear; we performed the first systematic review on their use in this context. Methods PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched in February 2021. We included English language clinical studies describing pre-operative low-calorie diet for laparoscopic cholecystectomy. Data were extracted for specifics of / adherence to diet, weight change, operative time / difficulty, complications and length of stay. Study quality was qualified using Scottish Intercollegiate Guidelines Network criteria and Jadad score. Results One randomised controlled trial (RCT) and one prospective observational study were identified. Both utilised a pre-operative very low-calorie diet of &amp;lt; 800 kcal/day. Overall weight loss was greater in patients deemed compliant with the intervention. Both demonstrated tendency towards reduced operative difficulty with the intervention. Only the RCT found improvement in operative time. Conclusions Pre-operative very low-calorie diets (&amp;lt; 800 kcal/day for two weeks) may aid weight loss and reduce operative difficulty in laparoscopic cholecystectomy, although evidence supporting their continued use is limited. Further RCTs are warranted to fully evaluate their role in clinical and cost-effectiveness.

International expert consensus on precision anatomy for minimally invasive pancreatoduodenectomy: PAM-HBP surgery project.

The anatomical structure around the pancreatic head is very complex and it is important to understand its precise anatomy and corresponding anatomical approach to safely perform minimally invasive pancreatoduodenectomy (MIPD). This consensus statement aimed to develop recommendations for elucidating the anatomy and surgical approaches to MIPD. Studies identified via a comprehensive literature search were classified using the Scottish Intercollegiate Guidelines Network method. Delphi voting was conducted after experts had drafted recommendations, with a goal of obtaining >75% consensus. Experts discussed the revised recommendations with the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Three clinical questions were addressed, providing six recommendations. All recommendations reached at least a consensus of 75%. Preoperatively evaluating the presence of anatomical variations and superior mesenteric artery (SMA) and superior mesenteric vein (SMV) branching patterns was recommended. Moreover, it was recommended to fully understand the anatomical approach to SMA and intraoperatively confirm the SMA course based on each anatomical landmark before initiating dissection. MIPD experts suggest that surgical trainees perform resection based on precise anatomical landmarks for safe and reliable MIPD.

Critical appraisal of clinical practice guidelines for the management of COVID-19: protocol for a systematic review

BackgroundIn December 2019, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 was identified as the cause of an acute respiratory disease, coronavirus disease 2019 (COVID-19). Given the lack of validated treatments, there is an urgent need for a high-quality management of COVID-19. Clinical practice guidelines (CPGs) are one tool that healthcare providers may use to enhance patient care. As such, it is necessary that they have access to high-quality evidence-based CPGs upon which they may base decisions regarding the management and use of therapeutic interventions (TI) for COVID-19. The purpose of the proposed study is to assess the quality of CPGs that make management or TI recommendations for COVID-19 using the AGREE II instrument.MethodsThe proposed systematic review will identify CPGs for TI use and/or the management of COVID-19. The MEDLINE, EMBASE, CINAHL, and Web of Science databases, as well as the Guidelines International Network, National Institute for Health and Clinical Excellence, Scottish Intercollegiate Guidelines Network, and the World Health Organization websites, will be searched from December 2019 onwards. The primary outcome of this study is the assessed quality of the CPGs. The quality of eligible CPGs will be assessed using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument. Descriptive statistics will be used to quantify the quality of the CPGs. The secondary outcomes of this study are the types of management and/or TI recommendations made. Inconsistent and duplicate TI and/or management recommendations made between CPGs will be compared across guidelines. To summarize and explain the findings related to the included CPGs, a narrative synthesis will also be provided.DiscussionThe results of this study will be of utmost importance to enhancing clinical decision-making among healthcare providers caring for patients with COVID-19. Moreover, the results of this study will be relevant to guideline developers in the creation of CPGs or improvement of existing ones, researchers who want to identify gaps in knowledge, and policy-makers looking to encourage and endorse the adoption of CPGs into clinical practice. The results of this review will be published in a peer-reviewed journal and presented at conferences.Systematic review registrationInternational Prospective Register for Systematic Reviews (PROSPERO)—CRD42020219944

Expert Consensus Guidelines: How to safely perform minimally invasive anatomic liver resection.

The concept of minimally invasive anatomic liver resection (MIALR) is gaining popularity. However, specific technical skills need to be acquired to safely perform MIALR. The "Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (PAM-HBP Surgery Consensus)" was developed as a special program during the 32nd meeting of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS). Thirty-four international experts gathered online for the consensus. A Research Committee performed a comprehensive literature review, classifying studies according to the Scottish Intercollegiate Guidelines Network method. Based on the literature review and experts' opinions, tentative recommendations were drafted and circulated among experts using online Delphi Rounds. Finally, formulated recommendations were presented online in the Expert Consensus Meeting of the JSHBPS on February 23rd, 2021. The final recommendations were validated and finalized by the 2nd Delphi Round in May 2021. Seven clinical questions were selected, and 22 recommendations were formulated. All recommendations reached more than 85% consensus among experts at the final Delphi Round. The Expert Consensus Meeting for safely performing MIALR has presented a set of clinical guidelines based on available literature and experts' opinions. We expect these guidelines to have a favorable effect on the safe implementation and development of MIALR.

International Expert Consensus on Precision Anatomy for minimally invasive distal pancreatectomy: PAM-HBP Surgery Project.

Surgical views with high resolution and magnification have enabled us to recognize the precise anatomical structures that can be used as landmarks during minimally invasive distal pancreatectomy (MIDP). This study aimed to validate the usefulness of anatomy-based approaches for MIDP before and during the Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (February 24, 2021). Twenty-five international MIDP experts developed clinical questions regarding surgical anatomy and approaches for MIDP. Studies identified via a comprehensive literature search were classified using Scottish Intercollegiate Guidelines Network methodology. Online Delphi voting was conducted after experts had drafted the recommendations, with the goal of obtaining >75% consensus. Experts discussed the revised recommendations in front of the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Four clinical questions were addressed, resulting in 10 recommendations. All recommendations reached at least a 75% consensus among experts. The expert consensus on precision anatomy for MIDP has been presented as a set of recommendations based on available evidence and expert opinions. These recommendations should guide experts and trainees in performing safe MIDP and foster its appropriate dissemination worldwide.

Accuracy of CREST Guideline in Management of Cellulitis in Emergency Department; a Systematic Review and Meta-analysis.

Introduction:Skin and soft tissue infections are important causes of outpatient visits to medical clinics or hospitals. This study aimed to review the literature for the accuracy of Clinical Resource Efficiency Support Team (CREST) guideline in management of cellulitis in emergency department. Method:Studies that had evaluated cellulitis patients using the CREST guideline were quarried in Scopus, Web of Science, and PubMed database, from 2005 to the end of 2020. The quality of the studies was evaluated using Scottish Intercollegiate Guideline Network (SIGN) checklist for cohort studies. Pooled area under the receiver operating characteristic curve (AUROC) of CREST guideline regarding the rate of hospital stay more than 24 hours, rate of revisit, and appropriateness of antimicrobial treatment in management of cellulitis in emergency department was evaluated.Results:Seven studies evaluating a total of 1640 adult cellulitis patients were finally entered to the study. In evaluation of the rate of the appropriate treatment versus over-treatment, the pooled AUROC was estimated to be 0.38 (95% confidence interval (CI): 0.06 – 0.82), indicating low accuracy (AUROC lower than 0.5) of guideline for antimicrobial choice. CREST II patients had a significantly lower odds ratio (OR) of revisiting the Emergency Department, OR=0.21 (95% CI: 0.009‎ – ‎ 0.47). Pooled AUROC value of 0.86 (CI95%: 0.84 – 0.89) showed accuracy of the CREST classification in prediction of being hospitalized more or less than 24 hours. Conclusion:CREST classification shows good accuracy in determining the duration of hospitalization or observation in ED but it could lead to inevitable over/under treatment with empirical antimicrobial agents.

Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities

Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities

EP.FRI.258 A closed loop audit of deep vein thrombosis prophylaxis in the acute surgical receiving unit of a large teaching hospital; reducing morbidity and mortality, and improving cost-effectiveness

Abstract Aims Acute surgical patients have a significant risk of venous thromboembolism (VTE) due to factors such as surgery, immobility, dehydration, and existing comorbidities. All patients admitted to an acute surgical unit should have their VTE risk assessed. Our aim was to assess VTE prophylaxis practices. Methods We performed a closed loop audit on DVT prophylaxis using the Scottish Intercollegiate Guidelines Network proforma. Data on anti-embolic stockings (AES) and low molecular weight heparin (LMWH) were collected and presented at a local audit meeting. The intervention included reinforcing the importance of VTE prophylaxis compliance amongst junior doctors and nursing staff, and provision of posters within the department and on patient trolleys. Data was collected to complete the audit cycle. Results A total of 171 patients were included. Prior to the intervention, 13.9% did not receive LMWH when indicated and 37.4% were non-compliant with AES. Overall, 40% had insufficient DVT thromboprophylaxis. Post implementation, 8.9% did not receive LMWH when indicated and 46.4% were noncompliant with AES. Overall, 50% had insufficient DVT thromboprophylaxis. LMWH compliance was 5.0% higher on re-auditing however AES compliance was 9.0% lower. Conclusions Adherence to thromboprophylaxis regulations was below expected standards. Thromboprophylaxis is cost-effective and prevents considerable morbidity and mortality, so ongoing audits alongside analyses of potential causes should be encouraged. We acknowledge the data’s limitations in that the reasons for low compliance cannot be ascertained here, but results suggest that there exists room for more interventions aiming to encourage a marked improvement both in LMWH and AES compliance.

Quality of life in adult patients with open-angle glaucoma:a systematic review

Abstract Background Assessment of the quality of life of glaucoma is an essential basis for their management in order to prevent deterioration of the disease. The aim of the study was to describe through a systematic review the quality of life of patients with open angle glaucoma and identify its associated factors. Methods It was a systematic review conducted based on the preferred reporting items for Systematic Reviews and Meta-analyses (PRISMA).Criteria for eligibility were all published population-based primary literature in Pubmed and Embase interface, written in English, since January 2014 to 31 December 2019. Electronic research was done through the following documentary query ((((‘glaucoma'[MeSH Terms]) AND (‘quality of life'[MeSH Terms])) AND (‘open angle glaucoma'[Title/Abstract])) AND (‘adult'[MeSH Terms])) AND (‘risk factors'[MeSH Terms]).Level of evidence and grades of recommendation was assessed according to the Scottish Intercollegiate Guidelines Network (SIGN). Results Among 139 articles, 15 were selected. Most of them were descriptive cross-sectional studies using different measuring instruments. We found that the quality of life of glaucoma patients varies according to the regions in Asia, Europe, America and Africa. The highest scores were recorded in Asia, followed by North America and Europe, which have very close scores. The risk factors associated with the quality of life of glaucoma patients were: Age, sex, level of education, professional status, marital status, visual acuity and disability, anxiety and depression. Conclusions The level of quality of life in this type of patient varies considerably between regions and countries and even in the same country. Associated factors are predominantly socio-demographic. Key messages The level of quality of life in patients with glaucoma varies considerably between regions and countries. Associated factors are predominantly socio-demographic.

Forthcoming UK asthma guidelines: an opportunity to improve asthma outcomes

The UK has a strong tradition of providing excellent, evidence-based asthma guidelines,1 and a totally inglorious one of having some of the worst asthma outcomes in the world.2 Addressing these poor outcomes must top the agenda for those taking forward the forthcoming UK National Institute for Health and Care Excellence (NICE), British Thoracic Society (BTS), and Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the diagnosis, monitoring, and management of chronic asthma.3 The challenge for the group developing these guidelines is to think radically, and produce a document that drives real change in outcomes, including mandating sanctions for non-compliance with new clinical practice recommendations.

Recommendations for prevention of infection in systemic autoimmune rheumatic diseases

ObjectivesTo develop recommendations for the prevention of infection in adult patients with systemic autoimmune rheumatic diseases (SARD). MethodsClinical research questions relevant to the objective of the document were identified by a panel of experts selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network criteria. Specific recommendations were made. ResultsFive questions were selected, referring to prevention of infection by Pneumocystis jirovecii with trimethoprim/sulfamethoxazole, primary and secondary prophylactic measures against hepatitis B virus, vaccination against human papillomavirus, vaccination against Streptococcus pneumoniae and vaccination against influenza virus, making a total of 18 recommendations, structured by question, based on the evidence found for the different SARD and/or expert consensus. ConclusionsThere is enough evidence on the safety and efficacy of vaccinations and other prophylactic measures against the microorganisms reviewed in this document to specifically recommend them for patients with SARD.

Comorbidity-Related Functional Implications In Traumatic Brain Injury: A Systematic Review

<h3>Objective(s)</h3> To systematically identify and synthesize existing evidence on comorbidity-related implications in adults with TBI. <h3>Data Sources</h3> Systematic searches were conducted in Medline, Cochrane Central Register of Controlled Trials, Embase, and PsycINFO, from May 1997 to September 2020. <h3>Study Selection</h3> Peer-reviewed English journal articles on prospective and retrospective longitudinal studies focusing on comorbidity in relation to cognitive or physical functioning in adult patients with TBI, were considered eligible. Letters to editors, reviews without data, case reports, conference abstracts, articles without primary data, studies that focus on therapeutic interventions, and theses, were excluded. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. <h3>Data Extraction</h3> Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations. <h3>Data Synthesis</h3> A total of 15,278 citations were abstracted from databases searched. Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes in patients with TBI. The extracted data were synthesized through tabulation and qualitative description. Cognitive and physical functioning were negatively affected by a wide range of studied comorbidities, including systemic medical diseases, psychiatric conditions, and neurological disorders. The effect of comorbidity, even within the same categories of comorbidity and functional outcome, differed across studies. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed. <h3>Conclusions</h3> This systematic review highlights the adverse effect of comorbidities on functional outcome in patients with TBI and enhances our understanding of their impact for both patients with TBI and clinicians who treat and rehabilitate these patients. It is essential to be aware of these comorbidity-related functional implications. PROSPERO registration (CRD 42017070033). <h3>Author(s) Disclosures</h3> The authors have no conflicts of interest to declare.

Risk assessment and classification for foot ulceration among patients with type 2 diabetes in South Korea.

This study aimed to investigate the distribution of foot conditions, the risk of foot ulceration and its associated factors in patients with diabetes. Few studies have focused on the risk of foot ulceration in patients with diabetes. A total of 267 patients with diabetes who attended outpatient clinics in two tertiary referral hospitals were recruited from June to September 2016. The risk of foot ulceration was classified using the American Diabetes Association (ADA), International Working Group on the Diabetic Foot (IWGDF) and Scottish Intercollegiate Guidelines Network (SIGN) classification systems. The risk categories of each system were reclassified into high- (categories of 2 and 3 for the ADA and IWGDF systems and high for the SIGN system) and low-risk. Foot deformity was the most prevalent condition (38.2%). Among 261 patients without active ulcers, between 17.6% to 35.2% were classified in the high-risk group and overall agreement among systems ranged from .42 to .56 of the kappa statistic. Insulin treatment was consistently associated with a high-risk of foot ulceration. As the risk varies between systems, nurses should select a suitable classification system through validation studies and assess the risk in patients with diabetes, particularly, those receiving insulin treatment.

Cardiac sarcoidosis: systematic review of the literature on corticosteroid and immunosuppressive therapies.

BackgroundCardiac sarcoidosis (CS) is a life-threatening condition in which clear recommendations are lacking. We aimed to systematically review the literature on cardiac sarcoidosis treated by corticosteroids and/or immunosuppressive agents in order to update the management of CS.MethodsUsing PubMed, Embase and Cochrane Library databases, we found original articles on corticosteroid and standard immunosuppressive therapies for CS that provided at least a fair Scottish Intercollegiate Guidelines Network (SIGN) overall assessment of quality and we analysed the relapse rate, major cardiac adverse events (MACEs) and adverse events. We based our methods on the PRISMA statement and checklist.ResultsWe retrieved 21 studies. Mean quality provided by SIGN assessment was 6.8 out of 14 (range 5–9). Corticosteroids appeared to have a positive impact on left ventricular function, atrioventricular block and ventricular arrhythmias. For corticosteroids alone, nine studies (45%, n=351) provided data on relapses, representing an incidence of 34% (n=119). Three studies (14%, n=73) provided data on MACEs (n=33), representing 45% of MACEs in patients treated by corticosteroid alone. Nine studies provided data on adjunctive immunosuppressive therapy, of which four studies (n=78) provided data on CS relapse, representing an incidence of 33% (n=26). Limitations consisted of no randomised control trial retrieved and unclear data on MACEs in patients treated by combined immunosuppressive agents and corticosteroids.ConclusionCorticosteroids should be started early after diagnosis but the exact scheme is still unclear. Studies concerning adjunctive conventional immunosuppressive therapies are lacking and benefits of adjunctive immunosuppressive therapies are unclear. Homogenous data on CS long-term outcomes under corticosteroids, immunosuppressive therapies and other adjunctive therapies are lacking.

Applying a novel approach to scoping review incorporating artificial intelligence: mapping the natural history of gonorrhoea

BackgroundSystematic and scoping literature searches are increasingly resource intensive. We present the results of a scoping review which combines the use of a novel artificial-intelligence-(AI)-assisted Medline search tool with two other ‘traditional’ literature search methods. We illustrate this novel approach with a case study to identify and map the range of conditions (clinical presentations, complications, coinfections and health problems) associated with gonorrhoea infection.MethodsTo fully characterize the range of health outcomes associated with gonorrhoea, we combined a high yield preliminary search with a traditional systematic search, then supplemented with the output of a novel AI-assisted Medline search tool based on natural language processing methods to identify eligible literature.ResultsWe identified 189 health conditions associated with gonorrhoea infection of which: 53 were identified through the initial ‘high yield’ search; 99 through the systematic search; and 124 through the AI-assisted search. These were extracted from 107 unique references and 21 International Statistical Classification of Diseases and Related Health Problems Ninth and Tenth Revision (ICD 9/10) or Read codes. Health conditions were mapped to the urogenital tract (n = 86), anorectal tract (n = 6) oropharyngeal tract (n = 5) and the eye (n = 14); and other conditions such as systemic (n = 61) and neonatal conditions (n = 7), psychosocial associations (n = 3), and co-infections (n = 7). The 107 unique references attained a Scottish Intercollegiate Guidelines Network (SIGN) score of ≥ 2++ (n = 2), 2+ (14 [13%]), 2- (30 [28%]) and 3 (45 [42%]), respectively. The remaining papers (n = 16) were reviews.ConclusionsThrough AI screening of Medline, we captured – titles, abstracts, case reports and case series related to rare but serious health conditions related to gonorrhoea infection. These outcomes might otherwise have been missed during a systematic search. The AI-assisted search provided a useful addition to traditional/manual literature searches especially when rapid results are required in an exploratory setting.